Covert splenic abscess: a continuing challenge.

Although splenic abscess is a rare cause of intra-abdominal sepsis, the mortality rate remains high especially in patients with silent or covert lesions. The clinical presentation and course of five patients with overt splenic abscess and seven patients with covert splenic abscess seen during a thirty year period were analyzed. Average age of patients with overt lesions was 44.5 years. Direct extension from a contiguous source, hematogenous spread from a distant site (metastatic) and trauma comprised the known etiologies. Clinical features of localized left upper quadrant sepsis were commonly present but only one patient exhibited multiple organ failure. The clinical diagnosis was established preoperatively in four patients (80%) and all underwent splenectomy without mortality. All resected spleens contained solitary abscesses. In contrast, patients with covert lesions tended to be older (average age 56.1 years), uniformly exhibited multiple organ failure and rarely demonstrated local clinical findings of left upper quadrant sepsis. Trauma was a less common etiology than metastatic infection and direct extension. Four patients died without operation. Three patients underwent exploration for unrelated reasons, but the diagnosis of splenic abscess was made intraoperatively in only one patient. Mortality among patients with covert lesions was 86%. Multiple splenic abscesses were demonstrated in all patients with covert lesions. Splenic abscess presents as a spectrum of clinical disease. Solitary lesions can be readily diagnosed and treated by splenectomy. Multiple abscesses are usually covert, associated with multiple organ failure and highly lethal. The role of splenectomy in patients with covert lesions remains unknown.