European Journal of Radiology 29 (1999) 259 – 261 Short communication Quiz case 5 C. Henk *, D. Fleischmann, K. Turetschek, G. Mostbeck Department of Radiology, Uniersity of Vienna, Vienna, Austria Received 26 November 1998; accepted 26 November 1998 1. History A 40-year-old woman was admitted to our emer- gency department because of fever, vomiting and crampy abdominal pain. On admission, there was a temperature of 39.8°C and abdominal pain on palpa- tion. Within 1 h, the patient developed septic shock, requiring use of intravenous catecholamines. Labora- tory findings demonstrated leucocytosis, increased infl- ammatory parameters and renal failure; amylasis and lipasis were normal. An abdominal computed tomogra- phy (CT) was performed (Fig. 1). 2. Imaging findings Plain CT (Fig. 1) demonstrated bilateral pleural effu- sions and atelectasis of both lower lobes. There was marked edematous infiltration of the retroperitoneal and mesenteric fat. The liver was slightly enlarged. There was only a very small spleen, measuring approx- imately 4 cm in diameter in the left subphrenic area. After recovery, repeat spiral CT with multiplanar reconstruction verified a small-sized spleen (Fig. 2). 3. Diagnosis Pneumococcal sepsis in a patient with hereditary hypoplasia of the spleen. 4. Discussion Clinical and basic studies have documented a high susceptibility to pneumococcal infections in asplenic humans and animals [1–5]. It has been suggested that autotransplantation of splenic tissue might be a method of providing host resistance when total splenectomy is necessary [2,3]. Fulminant pneumococcal septicemia mainly affects spenectomized individuals and is associ- ated with very substantial morbidity. In these patients, immunisation prior to splenectomy and daily prophy- lactic oral penicillin have partial preventive efficacy [1,4]. Invasive infections with streptococcus pneumonia present, in decreasing order, as bacteriemia without focus, pneumonia or meningitis, with other focal infec- tions, seen in rare cases. The differential diagnosis in patients with a small spleen on imaging studies includes hereditary hypo- plasia, status post-irradiation or infarction, the polysplenia syndrome and atrophy. The polysplenia syndrome is associated with pulmonary, cardiac, gas- trointestinal and GU genitourinary anomalies. In pa- tients with polysplenia syndrome, usually more than two spleens (usually two major +an indefinite number of splenules) are located on both sides of the mesogas- trium. Our patient denied irradiation, and there was no prior history of trauma. In an otherwise healthy woman, major splenic infarction would be very uncommon. Imaging findings in our patient include unspecific signs of septicemia and renal insufficiency with edema- tous infiltration of mesenteric and retroperitoneal fat plains, pleural effusion and pulmonary atelectasis. However, only a small-sized spleen was found in the typical location, confirmed by spiral CT after recovery due to adequate antibiotic treatment. Streptococcus * Corresponding author. Tel.: +43-140-400-4819; fax: +43-140- 400-4898. 0720-048X/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII:S0720-048X(98)00163-6