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Diagnosis and Treatment of Splenic Fungal Abscesses in the Immune-Suppressed Patient

Diagnosis and Treatment of Splenic Fungal Abscesses in the Immune-Suppressed Patient Abstract • In an 18-month period candidal splenic abscesses were diagnosed and treated in eight patients. Predisposing factors consisted of recent exposure to cytotoxic chemotherapy, long-term use of prednisone, neutropenia, antibiotic therapy for greater than three weeks, and gastrointestinal tract colonization with Candida. The patients had a clinical profile of nontoxic appearance with a temperature of more than 38.5 °C that was unresponsive to antibiotics, pain and tenderness over the upper abdominal quadrants, focal defects visualized on ultrasound and/or computed tomographic scans, and an elevated alkaline phosphatase level. Candida infection was confirmed by histologic examination of the liver and/or spleen in all patients. Diagnosis was made by percutaneous biopsy in one patient and exploratory laparotomy in seven. Five patients had splenectomy and antifungal drugs. In three patients the fungal abscesses resolved with amphotericin B therapy alone. Seven of eight patients were cured of their splenic abscesses, and five of eight were long-term survivors. (Arch Surg 1986;121:580-586) References 1. Tashjian LS, Abramson JS, Peacock JE: Focal hepatic candidiasis: A distinct clinical variant of candidiasis in immunocomprised patients . Rev Infect Dis 1984;6:689-703.Crossref 2. Johnson JD, Raff MJ: Fungal splenic abscess . Arch Intern Med 1984;144:1987-1993.Crossref 3. Berlow ME, Spirt BA, Weil L: CT followup of hepatic and splenic fungal microabscesses . J Comput Assist Tomogr 1984;8:42-45.Crossref 4. Dubuisson RL, Jones TB: Splenic abscess due to blastomycosis: Scintigraphic, sonographic and CT evaluation . Am J Radiol 1983;140:66-68. 5. Wald BR, Ortega JA, Ross L, et al: Candida splenic abscesses complicating acute leukemia of childhood treated by splenectomy . Pediatrics 1981;67:296-299. 6. Higgins TL, Calabres LH, Steeler LR: Opportunistic infections in patients with ectopic ACTH-secreting tumors . Cleve Clin Rev 1982;49: 43-49. 7. Page CP, Coltman CA, Robertson HD, et al: Candidal abscesses of the spleen in patients with acute leukemia . Surg Gynecol Obstet 1980;151: 604-608. 8. Larrien AJ, Wolma FJ, Wiener I, et al: Unusual splenic lesions in two immunosuppressed patients . South Med J 1981;74:1538-1540.Crossref 9. Coopersmith A, Ritchey AK, Zinkman WH: Fever of unknown origin and the value of gallium-67 and technetium-99m for defining abnormality of the spleen: A case report . Johns Hopkins Med J 1975;137:51-54. 10. Bodey GP, DeJongh D, Isassi A, et al: Hypersplenism due to disseminated candidiasis in a patient with acute leukemia . Cancer 1969;24: 417-420.Crossref 11. Bondestam S, Jansson S, Kivisaari L: Liver and spleen candidiasis: Imaging and verification by fine-needle aspiration biopsy . Br Med J 1981;282:1514.Crossref 12. Miller HJ, Greenfield LD, Wald BR: Candidiasis of the liver and spleen in childhood . Radiology 1982;142:375-380.Crossref 13. Shih WJ, Domstad PA, Deland FH: Discordant 99mTC sulfur colloid and 67Ga-citrate scintigrams in Aspergillus splenic abscess . Eur J Nucl Med 1982;7:272-274. 14. Ho B, Cooperberg PL, Li DKB, et al: Ultrasonography and computed tomography of hepatic candidiasis in immunosuppressed patients . J Ultrasound Med 1982;1:157-159. 15. Callen PW, Roy AF, Marcus FS: Ultrasonography and computed tomography in the evaluation of hepatic microabscesses in the immunosuppressed patient . Radiology 1980;136:433-434.Crossref 16. Bodey GP: Candidiasis in cancer patients . Am J Med 1984;77:13-19. 17. Hughes WT: Systemic candidiasis: Study of 109 fatal cases . Pediatr Infect Dis 1982;1:11-18.Crossref 18. Myerwitz RL, Pazin GJ, Allen CM: Disseminated candidiasis: Changes in incidence, underlying diseases and pathology . Am J Clin Pathol 1977;68:29-38. 19. Degregorio MW, Lee WMF, Linger CA, et al: Fungal infections in patients with acute leukemia . Am J Med 1982;73:543-548.Crossref 20. Lewis JH, Hasmukh RP, Hyman JZ: The spectrum of hepatic candidiasis . Hepatology 1982;2:479-487.Crossref 21. Pizzo PA, Robichaud KJ, Simon R, et al: Empiric antifungal therapy for cancer patients with prolonged fever and granulocytopenia , abstracted. Proc Am Assoc Cancer Res 1980;21:348. 22. Singer C, Kaplan MH, Armstrong D: Bacteremia and fungemia complicating neoplastic disease . Am J Med 1977;62:731-742.Crossref 23. Bodey GP, Rodriguez V, Chang Hui-Y, et al: Fever and infection in leukemic patients . Cancer 1978;41:1610-1622.Crossref 24. Hughes JM, Smith DR: Infection during induction of remission in ALL . Cancer 1973;31:1008-1014.Crossref 25. Degregorio MW, Lee WMF, Ries CA: Candida infections in patients with acute leukemia: Ineffectiveness of nystatin prophylaxis and relationship between esophageal and systemic candidiasis . Cancer 1982;50: 2780-2784.Crossref 26. Meunier-Carpentier F, Kiehn T, Armstrong D: Fungemia in the immunocompromised host: Changing patterns, antigenemia, high mortality . Am J Med 1981;71:363-370.Crossref 27. Meunier-Carpentier F: Chemoprophylaxis of fungal infections . Am J Med 1984;76:652-656.Crossref 28. Quintilian R, Owens NJ, Quercia RA, et al: Treatment and prevention of oropharyngeal candidiasis . Am J Med 1984;76:44-48. 29. Ezdinli EZ, O'Sullivan DO, Wasser LP, et al: Oral amphotericin for candidiasis in patients with hematologic neoplasms: An autopsy study . JAMA 1979;242:258-260.Crossref 30. Slavin RE, Dias MA, Sarol R: Cytosine arabinoside-induced gastrointestinal toxic alterations in sequential chemotherapeutic protocols: A clinical pathologic study of 33 patients . Cancer 1978;42:1747-1759.Crossref 31. Shaw MT, Spector MH, Ladman AJ: Effects of cancer, radiotherapy and cytotoxic drugs in intestinal structure and function . Cancer Treat Rev 1979;6:141-151.Crossref 32. Mulholland MW, Delaney JP: Neutropenic colitis and aplastic anemia: A new association . Ann Surg 1983;197:84-90. 33. Stone HH, Kolb LD, Currie CA, et al: Candida sepsis: Pathogenesis and principles of treatment . Ann Surg 1979;179:697-710.Crossref 34. Kirkpatrick CH: Host factors in defense against fungal infections . Am J Med 1984;77:1-12. 35. Catovsky D, Galton D, Robinson V: Myeloperoxidase-deficient neutrophils in acute myeloid leukemia . Scand J Haematol 1972;9:142.Crossref 36. Lawhorne TW, Zuidema GD: Splenic abscess . Surgery 1976;79: 686-689. 37. Chun CH, Raff MJ, Contreras L: Splenic abscesses . Medicine 1980; 59:50-65.Crossref 38. Krumbhaar ER, Stengel A: The spleen in the leukemias . Arch Pathol Lab Med 1942;34:117-132. 39. Yolken RH, Bishop CA, Townsend TR, et al: Infectious gastroenteritis in bone marrow transplant recipients . N Engl J Med 1982;306: 1009-1012.Crossref 40. Boyd WP, Bachman BA: Gastrointestinal infections in the compromised host . Med Clin North Am 1982;66:743-752. 41. McDonald G, Shulman HM, Sullivan KM, et al: Intestinal and hepatic complications of human bone marrow transplantation . Gastroenterology 1986;90:770-784. 42. Trier JS, Bjorkman DJ: Esophageal, gastric and intestinal candidiasis . Am J Med 1984;77:39-43. 43. Spencer GD, Shulman HM, Myerson D, et al: Diffuse intestinal ulceration after bone marrow transplantation: A clinical pathological study of 13 patients. Hum Pathol, in press. 44. Shao-Ru Chu, Tisnado J, Liu CI, et al: Bleeding cytomegalovirus ulcers of the colon: Barium enema and angiography . AJR 1981;136:1213-1215.Crossref 45. Foucar E, Mukai K, Foucar K, et al: Colon ulceration in lethal cytomegalovirus infection . Am J Clin Pathol 1981;76:788-801. 46. Alt B, Glass NR, Sallinger H: Neutropenic enterocolitis in adults: Review of the literature and assessment of surgical intervention . Am J Surg 1985;149:405-408.Crossref 47. Dosik GM, Luna M, Valdivieso M, et al: Necrotizing colitis in patients with cancer . Am J Med 1979;67:646-656.Crossref 48. Steinberg D, Gold J, Brodin A: Necrotizing enterocolitis in leukemia . Arch Intern Med 1973;131:538-544.Crossref 49. Moseley RH, Kris MG, Einzig A, et al: Respiratory alkalosis and abdominal pain heralding Candida hepatitis: Occurrence in patients with acute leukemia in remission . Arch Intern Med 1982;142:1495-1497.Crossref 50. Richter JM, Jacoby GA, Schapiro RH, et al: Pancreatic abscess due to Candida albicans . Ann Intern Med 1982;97:221-222.Crossref 51. Kozinn PJ, Tasehdijian CL, Kodsi BE, et al: Diagnosis of systemic or visceral candidiasis . Can Med Assoc J 1982;126:1386-1390. 52. Sanford GR, Merz WB, Wingard JR, et al: The value of fungal surveillance cultures as predictors of systemic fungal infections . J Infect Dis 1980;142:503-509.Crossref 53. Clift RA: Candidiasis in the transplant patient . Am J Med 1984;76: 34-38.Crossref 54. Weiner MH, Coats-Stephen M: Immunodiagnosis of systemic candidiasis: Mannan antigenemia detected by radioimmunoassay in experimental and human infections . J Infect Dis 1979;140:989-993.Crossref 55. Araj GJ, Hopter RL, Chesnut S, et al: Diagnostic value of the enzyme-linked immunosorbent assay for detection of Candida albicans cytoplasmic antigen in sera of cancer patients . J Clin Microbiol 1982;16: 46-52. 56. Jones JM: Granulomatous hepatitis due to Candida albicans in patients with acute leukemia . Ann Intern Med 1981;94:475-477.Crossref 57. Baruch Y, Levy Y, Brook G, et al: Splenic abscess diagnosed with the aid of abdominal computerized tomography: Report of two cases . Br J Surg 1981;68:137-138.Crossref 58. Johnson JD, Raff MJ, Drasin GF, et al: Radiology in the diagnosis of splenic abscess . Rev Infect Dis 1985;7:10-20.Crossref 59. Chulay JD, Lankerani MR: Splenic abscess: Report of ten cases and review of literature . Am J Med 1976;61:513-522.Crossref 60. Gadacz T, Way LW, Dunphy JE: Changing clinical spectrum of splenic abscesses . Am J Surg 1974;128:182-187.Crossref 61. Montgomerie JZ, Edwards JE, Guze LB: Synergism of amphotericin B and 5-fluorocytosine for Candida species . J Infect Dis 1975;132:82-86.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Diagnosis and Treatment of Splenic Fungal Abscesses in the Immune-Suppressed Patient

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Publisher
American Medical Association
Copyright
Copyright © 1986 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1986.01400050098013
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Abstract

Abstract • In an 18-month period candidal splenic abscesses were diagnosed and treated in eight patients. Predisposing factors consisted of recent exposure to cytotoxic chemotherapy, long-term use of prednisone, neutropenia, antibiotic therapy for greater than three weeks, and gastrointestinal tract colonization with Candida. The patients had a clinical profile of nontoxic appearance with a temperature of more than 38.5 °C that was unresponsive to antibiotics, pain and tenderness over the upper abdominal quadrants, focal defects visualized on ultrasound and/or computed tomographic scans, and an elevated alkaline phosphatase level. Candida infection was confirmed by histologic examination of the liver and/or spleen in all patients. Diagnosis was made by percutaneous biopsy in one patient and exploratory laparotomy in seven. Five patients had splenectomy and antifungal drugs. In three patients the fungal abscesses resolved with amphotericin B therapy alone. Seven of eight patients were cured of their splenic abscesses, and five of eight were long-term survivors. (Arch Surg 1986;121:580-586) References 1. Tashjian LS, Abramson JS, Peacock JE: Focal hepatic candidiasis: A distinct clinical variant of candidiasis in immunocomprised patients . Rev Infect Dis 1984;6:689-703.Crossref 2. Johnson JD, Raff MJ: Fungal splenic abscess . Arch Intern Med 1984;144:1987-1993.Crossref 3. Berlow ME, Spirt BA, Weil L: CT followup of hepatic and splenic fungal microabscesses . J Comput Assist Tomogr 1984;8:42-45.Crossref 4. Dubuisson RL, Jones TB: Splenic abscess due to blastomycosis: Scintigraphic, sonographic and CT evaluation . Am J Radiol 1983;140:66-68. 5. Wald BR, Ortega JA, Ross L, et al: Candida splenic abscesses complicating acute leukemia of childhood treated by splenectomy . Pediatrics 1981;67:296-299. 6. Higgins TL, Calabres LH, Steeler LR: Opportunistic infections in patients with ectopic ACTH-secreting tumors . Cleve Clin Rev 1982;49: 43-49. 7. Page CP, Coltman CA, Robertson HD, et al: Candidal abscesses of the spleen in patients with acute leukemia . Surg Gynecol Obstet 1980;151: 604-608. 8. Larrien AJ, Wolma FJ, Wiener I, et al: Unusual splenic lesions in two immunosuppressed patients . South Med J 1981;74:1538-1540.Crossref 9. Coopersmith A, Ritchey AK, Zinkman WH: Fever of unknown origin and the value of gallium-67 and technetium-99m for defining abnormality of the spleen: A case report . Johns Hopkins Med J 1975;137:51-54. 10. Bodey GP, DeJongh D, Isassi A, et al: Hypersplenism due to disseminated candidiasis in a patient with acute leukemia . Cancer 1969;24: 417-420.Crossref 11. Bondestam S, Jansson S, Kivisaari L: Liver and spleen candidiasis: Imaging and verification by fine-needle aspiration biopsy . Br Med J 1981;282:1514.Crossref 12. Miller HJ, Greenfield LD, Wald BR: Candidiasis of the liver and spleen in childhood . Radiology 1982;142:375-380.Crossref 13. Shih WJ, Domstad PA, Deland FH: Discordant 99mTC sulfur colloid and 67Ga-citrate scintigrams in Aspergillus splenic abscess . Eur J Nucl Med 1982;7:272-274. 14. Ho B, Cooperberg PL, Li DKB, et al: Ultrasonography and computed tomography of hepatic candidiasis in immunosuppressed patients . J Ultrasound Med 1982;1:157-159. 15. Callen PW, Roy AF, Marcus FS: Ultrasonography and computed tomography in the evaluation of hepatic microabscesses in the immunosuppressed patient . Radiology 1980;136:433-434.Crossref 16. Bodey GP: Candidiasis in cancer patients . Am J Med 1984;77:13-19. 17. Hughes WT: Systemic candidiasis: Study of 109 fatal cases . Pediatr Infect Dis 1982;1:11-18.Crossref 18. Myerwitz RL, Pazin GJ, Allen CM: Disseminated candidiasis: Changes in incidence, underlying diseases and pathology . Am J Clin Pathol 1977;68:29-38. 19. Degregorio MW, Lee WMF, Linger CA, et al: Fungal infections in patients with acute leukemia . Am J Med 1982;73:543-548.Crossref 20. Lewis JH, Hasmukh RP, Hyman JZ: The spectrum of hepatic candidiasis . Hepatology 1982;2:479-487.Crossref 21. Pizzo PA, Robichaud KJ, Simon R, et al: Empiric antifungal therapy for cancer patients with prolonged fever and granulocytopenia , abstracted. Proc Am Assoc Cancer Res 1980;21:348. 22. Singer C, Kaplan MH, Armstrong D: Bacteremia and fungemia complicating neoplastic disease . Am J Med 1977;62:731-742.Crossref 23. Bodey GP, Rodriguez V, Chang Hui-Y, et al: Fever and infection in leukemic patients . Cancer 1978;41:1610-1622.Crossref 24. Hughes JM, Smith DR: Infection during induction of remission in ALL . Cancer 1973;31:1008-1014.Crossref 25. Degregorio MW, Lee WMF, Ries CA: Candida infections in patients with acute leukemia: Ineffectiveness of nystatin prophylaxis and relationship between esophageal and systemic candidiasis . Cancer 1982;50: 2780-2784.Crossref 26. Meunier-Carpentier F, Kiehn T, Armstrong D: Fungemia in the immunocompromised host: Changing patterns, antigenemia, high mortality . Am J Med 1981;71:363-370.Crossref 27. Meunier-Carpentier F: Chemoprophylaxis of fungal infections . Am J Med 1984;76:652-656.Crossref 28. Quintilian R, Owens NJ, Quercia RA, et al: Treatment and prevention of oropharyngeal candidiasis . Am J Med 1984;76:44-48. 29. Ezdinli EZ, O'Sullivan DO, Wasser LP, et al: Oral amphotericin for candidiasis in patients with hematologic neoplasms: An autopsy study . JAMA 1979;242:258-260.Crossref 30. Slavin RE, Dias MA, Sarol R: Cytosine arabinoside-induced gastrointestinal toxic alterations in sequential chemotherapeutic protocols: A clinical pathologic study of 33 patients . Cancer 1978;42:1747-1759.Crossref 31. Shaw MT, Spector MH, Ladman AJ: Effects of cancer, radiotherapy and cytotoxic drugs in intestinal structure and function . Cancer Treat Rev 1979;6:141-151.Crossref 32. Mulholland MW, Delaney JP: Neutropenic colitis and aplastic anemia: A new association . Ann Surg 1983;197:84-90. 33. Stone HH, Kolb LD, Currie CA, et al: Candida sepsis: Pathogenesis and principles of treatment . Ann Surg 1979;179:697-710.Crossref 34. Kirkpatrick CH: Host factors in defense against fungal infections . Am J Med 1984;77:1-12. 35. Catovsky D, Galton D, Robinson V: Myeloperoxidase-deficient neutrophils in acute myeloid leukemia . Scand J Haematol 1972;9:142.Crossref 36. Lawhorne TW, Zuidema GD: Splenic abscess . Surgery 1976;79: 686-689. 37. Chun CH, Raff MJ, Contreras L: Splenic abscesses . Medicine 1980; 59:50-65.Crossref 38. Krumbhaar ER, Stengel A: The spleen in the leukemias . Arch Pathol Lab Med 1942;34:117-132. 39. Yolken RH, Bishop CA, Townsend TR, et al: Infectious gastroenteritis in bone marrow transplant recipients . N Engl J Med 1982;306: 1009-1012.Crossref 40. Boyd WP, Bachman BA: Gastrointestinal infections in the compromised host . Med Clin North Am 1982;66:743-752. 41. McDonald G, Shulman HM, Sullivan KM, et al: Intestinal and hepatic complications of human bone marrow transplantation . Gastroenterology 1986;90:770-784. 42. Trier JS, Bjorkman DJ: Esophageal, gastric and intestinal candidiasis . Am J Med 1984;77:39-43. 43. Spencer GD, Shulman HM, Myerson D, et al: Diffuse intestinal ulceration after bone marrow transplantation: A clinical pathological study of 13 patients. Hum Pathol, in press. 44. Shao-Ru Chu, Tisnado J, Liu CI, et al: Bleeding cytomegalovirus ulcers of the colon: Barium enema and angiography . AJR 1981;136:1213-1215.Crossref 45. Foucar E, Mukai K, Foucar K, et al: Colon ulceration in lethal cytomegalovirus infection . Am J Clin Pathol 1981;76:788-801. 46. Alt B, Glass NR, Sallinger H: Neutropenic enterocolitis in adults: Review of the literature and assessment of surgical intervention . Am J Surg 1985;149:405-408.Crossref 47. Dosik GM, Luna M, Valdivieso M, et al: Necrotizing colitis in patients with cancer . Am J Med 1979;67:646-656.Crossref 48. Steinberg D, Gold J, Brodin A: Necrotizing enterocolitis in leukemia . Arch Intern Med 1973;131:538-544.Crossref 49. Moseley RH, Kris MG, Einzig A, et al: Respiratory alkalosis and abdominal pain heralding Candida hepatitis: Occurrence in patients with acute leukemia in remission . Arch Intern Med 1982;142:1495-1497.Crossref 50. Richter JM, Jacoby GA, Schapiro RH, et al: Pancreatic abscess due to Candida albicans . Ann Intern Med 1982;97:221-222.Crossref 51. Kozinn PJ, Tasehdijian CL, Kodsi BE, et al: Diagnosis of systemic or visceral candidiasis . Can Med Assoc J 1982;126:1386-1390. 52. Sanford GR, Merz WB, Wingard JR, et al: The value of fungal surveillance cultures as predictors of systemic fungal infections . J Infect Dis 1980;142:503-509.Crossref 53. Clift RA: Candidiasis in the transplant patient . Am J Med 1984;76: 34-38.Crossref 54. Weiner MH, Coats-Stephen M: Immunodiagnosis of systemic candidiasis: Mannan antigenemia detected by radioimmunoassay in experimental and human infections . J Infect Dis 1979;140:989-993.Crossref 55. Araj GJ, Hopter RL, Chesnut S, et al: Diagnostic value of the enzyme-linked immunosorbent assay for detection of Candida albicans cytoplasmic antigen in sera of cancer patients . J Clin Microbiol 1982;16: 46-52. 56. Jones JM: Granulomatous hepatitis due to Candida albicans in patients with acute leukemia . Ann Intern Med 1981;94:475-477.Crossref 57. Baruch Y, Levy Y, Brook G, et al: Splenic abscess diagnosed with the aid of abdominal computerized tomography: Report of two cases . Br J Surg 1981;68:137-138.Crossref 58. Johnson JD, Raff MJ, Drasin GF, et al: Radiology in the diagnosis of splenic abscess . Rev Infect Dis 1985;7:10-20.Crossref 59. Chulay JD, Lankerani MR: Splenic abscess: Report of ten cases and review of literature . Am J Med 1976;61:513-522.Crossref 60. Gadacz T, Way LW, Dunphy JE: Changing clinical spectrum of splenic abscesses . Am J Surg 1974;128:182-187.Crossref 61. Montgomerie JZ, Edwards JE, Guze LB: Synergism of amphotericin B and 5-fluorocytosine for Candida species . J Infect Dis 1975;132:82-86.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: May 1, 1986

References