8 October 2009
WAS SPLENECTOMY NECESSARY FOR DIAGNOSIS OF YERSINIOSIS IN AN 18-YEAR-OLD PATIENT?
Splenectomy is one of the diagnostic and therapeutic methods used in management of a range of disorders. There are numerous surgical and haematological indications for splenectomy. In the 1970s and 1980s, splenectomy was performed to assess its involvement in a neoplastic process. Laparoscopy was used for staging of Hodgkin's and non-Hodgkin's lymphomas as an alternative to staging laparotomy.1–3 In exceptional cases, a physician has to opt for splenectomy as an ultimate diagnostic tool.
In this letter we report a case of an 18-year-old boy who was admitted to the Department of Oncology because of fever, weakness, loss of weight and multiple foci in the spleen found on an ultrasound examination. For 6 weeks before admission, the patient had recurrent fever up to 40°C for a period of several days. He had no history of headache, diarrhea, vomiting, chest pain, shortness of breath, recent sore throat, rashes. He had never travelled to a tropical country and had no known exposure to tuberculosis. Recently, none of the close family members suffered from a serious disease. Family cancer history included lung and brain cancers in grandparents. The patient neither had pets nor visited farms. He negated to be sexually active. He denied usage of drugs, alcohol or smoking. Paracetamol was the only medication used occasionally. Two years earlier, he had been hospitalized and cat-scratch disease was diagnosed.
Presently, upon admission, physical examination revealed no significant abnormalities; the spleen was not palpable under the costal arch. Extensive laboratory analyses were performed: elevated erythrocyte sedimentation rate (73 mm/h) and C-reactive protein level (81 mg/L) were found. Red blood cell and platelet counts were normal while white blood cell count, especially neutrophils, was elevated. The levels of immunoglobulins IgG and IgE were slightly elevated. Markers of thyroid were within the range of normal. Blood and urine cultures were negative. Antibodies against cytomegalovirus, Epstein–Barr virus and toxoplasmosis were not detected in the patient serum. According to clinical symptoms, we have not detected endocarditis by echocardiogram examination. Bone scintigraphy revealed no pathology. Abdominal ultrasound examination showed multiple, round, well-defined hypoechogenic lesions (12–19 mm in diameter) in the spleen and lymphadenitis in the abdomen (Fig. 1). These lesions were also visible on contrast-enhanced abdominal computed tomography (CT) while scintigraphy of the spleen was negative (Fig. 2). The mesenteric lymph node biopsy was performed, and in view of histopathologic examination, lymphadenitis reactiva was diagnosed. Antibiotic treatment was modified to include clarythromycine, cefoperazonum+sulbactamum, vancomycin and teicoplanin. Finally, treatment resulted in normalization of the body temperature and eventual recovery of the general conditions of the patient.
In search of the cause of the ailment, bone marrow biopsy was performed. Histopathologic analysis of the aspirate from the posterior iliac crest revealed no abnormalities; in particular, neither granulomas nor Reed-Sternberg cells were observed. Eventually, the patient underwent splenectomy. The histopathologic examination of the spleen revealed signs of infection suggestive of pseudotuberculosis, yersiniosis, tularemia or cat-scratch disease. ELISA test confirmed yersiniosis infection. An indirect fluorescent-specific antibody test detecting a humoral response to Bartonella henselae did not confirm cat-scratch disease. Presently, the patient continues to be in good health.
In the presented case, primal signs of the disease were fever, weakness and loss of body weight. On ultrasound and CT examination of the abdomen, enlargement of mesenteric lymph nodes and focal lesions in the spleen were detected. For diagnostic purposes, mesenteric lymph node biopsy was performed. Histopathologic analysis of the obtained samples revealed solely lymphadenitis reactiva; therefore, decision to perform diagnostic splenectomy was made. Accordingly, the final diagnosis was made in view of the results of serologic tests and histopathologic examination of the removed spleen. Histopathologic analysis revealed foci of necrosis containing purulent inflammatory exudates surrounded by histocytes of granuloma-like character. Such morphology of the lesions argues for their infectious origin. They were previously reported in cat-scrach disease, yersiniosis and tularemia.1,4
Numerous lesions in the spleen observed on imagine studies have to be differently diagnosed with abscesses. Our differential diagnosis aimed at exclusion of infectious diseases.
Yersinia is associated with several well-known syndromes, such as enterocolitis and mesenteric lymphadenitis, but it can also give rise to a wide variety of uncommon manifestations.5 Few reports on granulomatous liver and spleen disease due to Yersinia enterocolitica have been published. Its diagnosis can be obtained by using novel diagnostic methods, that is, demonstration by indirect immunofluorescence of Yersinia bacilli in biopsy specimens or determination of class-specific circulating antibodies against virulence proteins by immunoblotting techniques.6
Spleen lesions on radiological imaging have been observed in patients with a variety of neoplastic disorders. Granulomas have been found in association with Hodgkin's or non-Hodgkin's lymphoma.
The signs and symptoms of splenic abscess have been well described but are not very specific. Therefore, splenic abscess remains a substantial diagnostic challenge.
In a significant number of cases, it will prove impossible to find a clear reason for the presence of spleen granulomas; therefore, the physician has to opt for diagnostic splenectomy. Only histopathologic examination allows for exclusion of a neoplastic disorder as the underlying cause. In our case, removal of the spleen, that is, the only foci of infection residual after wide-spectrum antibiotic therapy, had also therapeutic significance. Since the moment of surgery, the patient continues to be in good health with no sign of infection.
We concluded that currently, the indications for splenectomy are rigorously determined, and only in extremely rare situations is splenectomy performed for diagnostic purposes. In the presented case, splenectomy had both diagnostic and therapeutic significance.