A 49-year-old woman comes to the emergency department due to 2 weeks of worsening left-sided abdominal pain, fever, and chills. The pain is constant, deep, and radiates to the back. The patient also has had decreased appetite and notes a 2.3-kg (5-lb) weight loss during this period. She has no dysuria, urinary frequency, hematuria, diarrhea, or constipation. The patient underwent laparoscopic cholecystectomy 2 weeks ago for acute calculus cholecystitis. She has a history of type 2 diabetes mellitus, hypertension, and hypothyroidism. Temperature is 39.5 C (103.1 F), blood pressure is 130/80 mm Hg, pulse is 102/min, and respirations are 16/min. Cardiopulmonary examination shows no abnormalities. The spleen is enlarged and tender; there is no hepatomegaly. Bowel sounds are present. The remainder of the examination is normal. Which of the following is the most likely diagnosis?

Question

A 49-year-old woman comes to the emergency department due to 2 weeks of worsening left-sided abdominal pain, fever, and chills.  The pain is constant, deep, and radiates to the back.  The patient also has had decreased appetite and notes a 2.3-kg (5-lb) weight loss during this period.  She has no dysuria, urinary frequency, hematuria, diarrhea, or constipation.  The patient underwent laparoscopic cholecystectomy 2 weeks ago for acute calculus cholecystitis.  She has a history of type 2 diabetes mellitus, hypertension, and hypothyroidism.  Temperature is 39.5 C (103.1 F), blood pressure is 130/80 mm Hg, pulse is 102/min, and respirations are 16/min.  Cardiopulmonary examination shows no abnormalities.  The spleen is enlarged and tender; there is no hepatomegaly.  Bowel sounds are present.  The remainder of the examination is normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient who recently underwent laparoscopic cholecystectomy for cholecystitis now has high fever and tender splenomegaly, raising strong suspicion for splenic abscess, a rare, potentially life-threatening complication of bacteremia from a distant infection (eg, infective endocarditis, cholecystitis). Risk is greatest in those with immunocompromise from HIV, hematologic malignancy, or diabetes mellitus. Patients usually have persistent fever and left upper quadrant pain (sometimes radiating to the back), with or without splenomegaly. Anorexia and weight loss may also be seen. Laboratory studies will show leukocytosis with left shift, and chest x-ray frequently reveals an elevated left hemidiaphragm (and/or left pleural effusion). Diagnosis is made with CT scan of the abdomen; antibiotic therapy plus splenectomy is generally required because many patients fail percutaneous aspiration (due to the presence of occult microabscesses). (Choice A) Pancreatic pseudocyst, a walled-off collection of fluid around the pancreas following pancreatitis, is generally asymptomatic but may occasionally become infected, leading to fever and epigastric pain that radiates to the back. However, splenomegaly would be atypical, and this patient does not have risk factors for (eg, alcohol abuse) or a recent history of pancreatitis. (Choice B) Infectious mononucleosis, a manifestation of initial Epstein-Barr virus, frequently causes tender splenomegaly. However, most cases occur in young adults; high fever is uncommon; and patients generally have tonsillitis/pharyngitis, lymphadenopathy, and severe fatigue. (Choice C) Non-Hodgkin lymphoma can present with splenomegaly, weight loss, and waxing/waning fevers. However, high fevers are uncommon, and significant splenic tenderness/pain rarely occurs. In addition, most patients have diffuse lymphadenopathy. (Choice E) Splenic infarction usually presents with left upper quadrant pain. Although fever and splenomegaly can occasionally occur, most patients with splenic infarction have an underlying hypercoagulable disorder, a source of embolic disease (eg, atrial fibrillation), a myeloproliferative neoplasm, or hemoglobinopathy (eg, sickle cell disease). This patient's weight loss, high fever, recent cholecystectomy, and lack of risk factors for splenic infarction make splenic abscess more likely. (Choice F) Splenic venous thrombosis usually occurs in the setting of portal hypertension from liver disease or pancreatitis. Although splenomegaly can occur, patients would not typically have high fever and weight loss. Educational objective: Splenic abscess is a rare, life-threatening complication of bacteremia from a distant infection (eg, infective endocarditis, cholecystitis). Manifestations generally include persistent high fever and tender splenomegaly. Diagnosis is made with CT scan of the abdomen; antibiotic therapy and splenectomy are generally required.

A 49-Year-Old Woman Comes to the Emergency Department Due to 2