We present an uremic patient on chronic hemodialysis with splenic septic emboli associated with active infective endocarditis and anaerobic bacteremia complicated by ruptured spleen. A 62-year-old female patient was admitted because of fever and pain in the left upper abdomen and swelling and hematoma around the left brachiocephalic arteriovenous fistula. Transthoracic echocardiography revealed mobile hyperechoic mass (vegetation) on the anterior mitral valve. Abdominal ultrasound scan showed multiple hypoechoic lesions of the enlarged spleen, described as possible necroses or abscesses, and computed tomography showed low-density inhomogeneous lesions in the enlarged spleen with large perisplenic hematoma, with spleen rupture. Blood culture revealed anaerobic Gram-negative bacilli (Bacteroides spp.), ampicillin resistant. This is the first report of splenic rupture associated with anaerobic bacteremia and splenic septic emboli in a uremic patient on chronic hemodialysis. Splenic septic emboli with abscess/infarction in hemodialysis patients are a rare disorder but could be a consequence of dialysis access site infection and might predispose to splenic rupture. Ultrasound scan of abdomen is fast, inexpensive and easy to perform. As mortality is high, early surgical intervention on vascular access is mandatory.

Keywords:
Endocarditis, Spleen, Hemodialysis
1.
Trouillet JL, Hoen B, Battik R, Michel PL, Canavy I, Brochet E, Wolff M, Selton-Suty C: Splenic involvement in infectious endocarditis. Association for the Study and Prevention of Infectious Endocarditis. Rev Med Interne 1999;20:258-263.
2.
Ting W, Silverman NA, Arzouman DA, Le-vitsky S: Splenic septic emboli in endocarditis. Circulation 1990;82:105-109.
3.
Castro CE, Madariaga MG: Vascular access-related infections in HIV patients undergoing hemodialysis: case description and literature review. Braz J Infect Dis 2008;12:531-535.
4.
Kessler M, Hoen B, Mayeux D, Hestin D, Fontenaille C: Bacteremia in patients on chronic hemodialysis. Nephron 1993;64:95-100.
5.
Fonseca V, Baillod R, Berger L, Fernando O, Moorhead J: Splenic abscess in patients on hemodialysis. Am J Kidney Dis 1990;15:273-275.
6.
Fernández Guerrero ML, Álvarez B, Manzarbeitia F, Renedo G: Infective endocarditis at autopsy: a review of pathologic manifestations and clinical correlates. Medicine (Baltimore) 2012;91:152-164.
7.
Yoshikai M, Kamachi M, Kobayashi K, Murayama J, Kamohara K, Minematsu N: Splenic abscess associated with active infective endocarditis. Jpn J Thorac Cardiovasc Surg 2002;50:478-480.
8.
Nelken N, Ignatius J, Skinner M, Christensen N: Changing clinical spectrum of splenic abscess. Am J Surg 1987;154:27-34.
9.
Johnson JD, Raff MJ, Barnwell PA, Chun CH: Splenic abscess complicating infectious endocarditis. Arch Intern Med 1983;143:906-912.
10.
McCarthy JT, Steckelberg JM: Infective endocarditis in patients receiving long-term hemodialysis. Mayo Clin Proc 2000;75:1008-1014
11.
Robinson DL, Fowler VG, Sexton DJ, Corey RG, Conlon PJ: Bacterial endocarditis in hemodialysis patients. Am J Kidney Dis 1997;30:521-524.
12.
Manian FA: Vascular and cardiac infections in end-stage renal disease. Am J Med Sci 2003;325:243-250.
13.
Cheesbrough JS, Jones EW, Finch RG: The management of splenic abscess. Q J Med 1985;57:653-657.
14.
Chuang FR, Lee CH, Chen JB, Cheng YF, Yang BY, Hsu KT, Wu MS: Extra-renal abscess in chronic hemodialysis patients. Ren Fail 2002;24:511-521.
15.
Nakamura T, Iwashima A, Honma T, Higuma N, Tamura K: Splenic abscess in a patient on hemodialysis. Nephron 1992;60:255-256.
16.
Kim HS, Cho MS, Hwang SH, Ma SK, Kim SW, Kim NH, Choi KC: Splenic abscess associated with endocarditis in a patient on hemodialysis: a case report. J Korean Med Sci 2005;20:313-315.
17.
Toprak O, Cağlar BU, Bayata S, Yaşar H, Tanrisev M, Ersoy R, Cirit M: Severe mitral valve infective endocarditis with widespread septic emboli in a patient with permanent hemodialysis catheter. Anadolu Kardiyol Derg 2004;4:374-375.
18.
Gedik E, Girgin S, Aldemir M, Keles C, Tuncer MC, Aktas A: Non-traumatic splenic rupture: report of seven cases and review of the literature. World J Gastroenterol 2008;14:6711-6716.
19.
Opatrny K Jr: Hemostasis disorders in chronic renal failure. Kidney Int Suppl 1997;62:S87-S89.
20.
Kim HJ, Lee GW, Park DJ, Lee JD, Chang SH: Spontaneous splenic rupture in a hemodialysis patient. Yonsei Med J 2005 30;46:435-438.
21.
Hakoda S, Shinya H, Kiuchi S: Spontaneous splenic rupture caused by splenic peliosis of a hemodialysis patient with chronic renal failure receiving erythropoietin. Am J Emerg Med 2008;26:109.e1-2.
22.
Ram R, Swarnalatha G, Prasad N, Murty KV: Pathological rupture of spleen in a haemodialysis patient due to tuberculosis. Nephrol Dial Transplant 2006;21:2994-2995.
23.
Katsanos KH, Theodorou J, Katopodis KP, Siamopoulos KC: Spontaneous splenic rupture complicating pancreatitis in a chronic hemodialysis patient. Clin Nephrol 2004;61:448-449.
24.
Gascón A, Iglesias E, Bélvis JJ, Berisa F: The elderly haemodialysis patient with abdominal symptoms and hypovolemic shock - splenic rupture secondary to splenic infarction in a patient with severe atherosclerosis. Nephrol Dial Transplant 1999;14:1044-1045.
25.
Gananadha S, Leibman S: Spontaneous splenic rupture in a patient with bacterial endocarditis. J Am Coll Surg 2006;203:127.
26.
Winearls JR, McGloughlin S, Fraser JF: Splenic rupture as a presenting feature of endocarditis. Eur J Cardiothorac Surg 2009;35:737-739.
27.
Yang MH, Wu CC, Jean WH, Lu CW, Chuang YH, Lin TY: Spleen rupture after mitral valve replacement for infective endocarditis. Acta Anaesthesiol Taiwan 2008;46:191-193.
28.
Khan MF, Ghani S: Infective endocarditis complicated by splenic rupture and fatal intra-abdominal haemorrhage. BMJ Case Rep 2009;2009. pii: bcr01.2009.1460.
29.
Lentino JR, Baddour LM, Wray M, Wong ES, Yu VL: Staphylococcus aureus and other bacteremias in hemodialysis patients: antibiotic therapy and surgical removal of access site. Infection 2000;28:355-360.
© 2013 S. Karger AG, Basel
2013
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