Infarction of Spleen as a Rare Complication of Drug-resistant Enteric Fever in a Child: A Case Report

Kunal Kumar¹, Deepak Kumar², Vikas Kumar³, Krishnan Rajeshwari⁴

^1-4Department of Paediatrics, Lok Nayak and Associated Hospitals, Maulana Azad Medical College, Delhi, India

Corresponding Author: Deepak Kumar, Department of Paediatrics, Lok Nayak and Associated Hospitals, Maulana Azad Medical College, Delhi, India, Phone: +91 9211377848, e-mail: deepakk70@gmail.com

Received on: 17 November 2022; Accepted on: 09 January 2023; Published on: 15 April 2023

ABSTRACT

Splenic infarct is an extremely rare complication of enteric fever in children. It could be misdiagnosed as a splenic abscess where computed tomography (CT) has to be used over ultrasonography to confirm the diagnosis. We reported a young girl who was presented with fever and abdominal pain whose diagnosis of enteric fever was made by Widal and blood culture. She had pain over the upper left abdomen; ultrasonography revealed a splenic abscess; however, the clinical course of the patient doubted the diagnosis for which CT was done, which confirmed the lesion as splenic infarct.

How to cite this article: Kumar K, Kumar D, Kumar V, et al. Infarction of Spleen as a Rare Complication of Drug-resistant Enteric Fever in a Child: A Case Report. Pediatr Inf Dis 2023;5(1):30-32.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.

Keywords: Complications, Enteric fever, Splenic abscess, Splenic infarct, Typhoid.

INTRODUCTION

Enteric fever is still a major public health issue, especially in developing countries. Mortalities are reported more in younger children. Drug resistance remains a concern as complications and mortalities are more frequently seen with these bacterial strains.¹ Complications involving gastrointestinal, hepatobiliary, central nervous, and musculoskeletal systems are well-known.² Splenic abscess and thrombosis are described limitedly in literature,³^,⁴ whereas splenic infarction is a very rarely reported entity as a complication of enteric fever in children.⁵ Most of the reports are described in young adults.⁶^,⁷ The importance of CT over ultrasonography is emphasized as infarcts may get misdiagnosed as an abscess if we rely solely on ultrasonography. Splenic abscesses should be differentiated from infarcts as early as possible to avoid splenic rupture in case of splenic infarcts.⁸ Also, this will help to rationalize the duration of antibiotic therapy. We are reporting a young female diagnosed with isolated splenic infarct as a very rare complication associated with enteric fever.

CASE DESCRIPTION

A case of young 6-year-old female was reported from a tertiary care hospital located in Delhi, India, who came to the emergency room with high-intensity fever, abdominal pain, vomiting, and anorexia for the past 7 days. The general condition of patient was very sick. On examination, vitals showed heart rate—150/minute, respiratory rate—34/minute, temperature 104°F, blood pressure—70/50, and pallor was present. Abdominal examination showed hepatomegaly with tender splenomegaly in left hypochondrium. Blood investigation revealed anemia (hemoglobin (Hb)—7.5), leukopenia (total leukocyte count—4,200), thrombocytopenia (platelet—80,000), blood urea nitrogen—22, serum electrolytes—145/4.5, transaminitis (serum glutamic oxaloacetic transaminase—250, serum glutamic pyruvic transaminase—175), Bilirubin: 0.6, prothrombin time—12 seconds, international normalized ratio—0.9, erythrocyte sedimentation rate—65 mm in first hour and C-reactive protein—178 mg/dL. Chest skiagram and electrocardiography (ECG) were normal. Her Widal test showed 1:100 titers of Salmonella Paratyphi (S. Paratyphi) A on day 5th, which rose to 1:680 on 14th day. Blood culture made the confirmation of S. Paratyphi; the isolate was resistant to chloramphenicol, tetracycline, ciprofloxacin, amikacin, cefaclor, trimethoprim/sulphamethoxazole, and ceftriaxone but sensitive to piperacillin-tazobactam, imipenem, and azithromycin. Serology for malaria, dengue, scrub typhus, leptospirosis, and brucella was negative.

On evaluating the patient further, abdominal ultrasound (USG) of the patient showed splenomegaly with ill-defined heterogeneously hypoechoic lesions in the parenchyma of the spleen suggestive of abscess reported by the radiologist (Fig. 1). The patient was managed based on the culture sensitivity report and started on injection of meropenem 300 mg thrice a day and azithromycin 300 mg once a day, along with intravenous fluid and analgesics. Patient had defervescence on the 5th day of admission with clinical improvement. We repeated the USG abdomen and found that the splenic lesion (?Abscess) was the same in size, which was incompatible with the clinical resolution. Knowing the splenic infarct is a rare complication of certain infections, including enteric fever, contrast-enhanced CT abdomen was done, which showed splenomegaly of 12.5 cm and multiple wedge-like confluent areas of infarct reaching the splenic capsule (Fig. 2). CT angiography was found unremarkable. Sickle cell anemia and other hemoglobinopathies were ruled out by normal Hb electrophoresis. Test for thrombophilic factors (protein C/S, antinuclear antibody, anti-neutrophilic cytoplasmic antibody, and anticardiolipin antibody) were negative. Patient was given 10 days of antibiotics and was discharged. On follow-up, after 4 weeks, the patient was found healthy, and repeat ultrasonography showed resolution.

Fig 1: Ultrasonography (USG) of the abdomen showing hypoechoic lesion (blue arrow) in splenic parenchyma

Figs 2A and B: (A) Computed tomography (CT) scan showing wedge-shaped hypoechoic splenic infarct reaching up to capsulein coronal (B) and sagittal section

DISCUSSION

Splenic infarcts are frequently seen with hematological or rheumatological illnesses.⁹ Certain infections like malaria, cytomegalovirus, Epstein–Barr virus, and human immunodeficiency viruses are known to cause splenic infarcts.¹⁰^,¹¹ The underlying mechanism are all presumptions and include hypercoagulability in hyperinflammatory state, deposition of excessive circulatory immune complexes in microvasculature, and imbalance between demand and blood supply of inflamed infective organ.¹² The splenic infarcts may go undiagnosed until a life-threatening splenic hemorrhage or rupture occurs, for which timely and accurate diagnosis is crucial. Ultrasonography can be used for the diagnosis, but it is less sensitive; as seen in our case, the infarct was first reported splenic abscess on ultrasonogram. Whereas, CT scan precisely identify the defect and is modality of choice for accurate diagnosis.

The primary treatment for enteric fever involves the use of antibiotics, with the duration of treatment depending on the presence of complications and extraintestinal symptoms. The administration of third-generation cephalosporins, fluoroquinolones, ampicillin, or co-trimoxazole antibiotics may suffice for 5–7 days; however, if the infection is invasive or resistant to drugs, a prolonged treatment course may be necessary.

Though the complication is rare, early identification, more importantly, differentiation of an infarct from an abscess may prevent fatal complications like splenic hemorrhage and rupture, also the antibiotic therapy could be rationalized and curtailed short.

CONCLUSION

Although not frequently reported, splenic infarction can be a complication of enteric infections. Patients with this condition typically experience pain and tenderness in the left upper quadrant, which can be overlooked. Laboratory results are not particularly informative, so early diagnosis using imaging techniques, particularly CT scans, is critical for prompt treatment and to avoid additional complications and health risks.

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