Infective endocarditis and infected aneurysm of splenic artery post colonoscopy
A 68-year-old male presented a two-week history of malaise, left-sided abdominal pain and intermittent fever. The only apparent incident of significance prior to presentation was a colonoscopy performed two weeks ago for investigation into his recent change in bowel habit. The colonoscopy was performed with adequate bowel preparation and revealed a 10 mm pedunculated rectal polyp. Apart from a rectal polypectomy with snare diathermy, 3 mm-diameter biopsies were taken randomly from the terminal ileum, ascending colon and descending colon. Hemostatic clips and adrenaline injection were not required as there was no significant bleeding. There was no significant past medical, surgical or dental histories. He does not take any regular medications and has no known allergies. There was no recent travel, sick or animal contacts. He does not smoke and only drinks alcohol socially. He denies any form of illicit drug use.\nHistological examination confirmed the rectal polyp as a tubular adenoma. He was well the next day following polypectomy but presented four days later with left upper quadrant pain radiating to the back and minor rectal bleeding. Six days following colonoscopy and polypectomy he developed sepsis, supported by leukocytosis of 18.1 (range 4-11), CRP of 234 (normal range <5) and ESR of 55 mm/h (normal 2-14). He was immediately commenced on amoxycillin/clavulanic acid and treated as colitis by his general practitioner. Due to a lack of clinical improvement despite oral antibiotic, a contrast CT scan of his abdomen and pelvis was performed. There were CT evidence of distal splenic artery aneurysm with complete obliteration distally as well as splenomegaly with most of the spleen occupied by multiple cystic lesions ().\nBlood cultures and CT-guided splenic abscess aspiration were collected immediately, followed by administration of intravenous antibiotics (ceftriaxone and metronidazole). Multiple sets of blood cultures and splenic aspirate cultures were positive for Enterococcus faecalis on day one, sensitive to amoxycillin and vancomycin. Transthoracic echocardiogram showed moderately severe aortic regurgitation and an aortic valve vegetation (1.4 × 0.9 cm) situated at the right coronary cusp with localized leaflet prolapse and perforation. Apart from that, no other valvular lesion was detected and both ventricular systolic functions were well-preserved. These findings were confirmed on a subsequent transesophageal echocardiogram.\nOpen splenectomy was performed via a roof-top incision. Macroscopically, the spleen was grossly enlarged with multiple loculations of abscess (). The infected aneurysm of splenic artery was densely adherent to the retroperitoneum and pancreas, rendering its excision challenging. A decision was then made to suture-ligate it proximally. Post-splenectomy recovery was uneventful. Bioprosthetic aortic valve replacement was performed one week after splenectomy. Culture of the native aortic valve was positive for Enterococcus faecalis. Recovery post-cardiac surgery was uncomplicated. He was then discharged on ampicillin 2 g every four hours for a total of six weeks. He remained well and asymptomatic at his follow up eight weeks after discharge.