Case Presentation: A 72 year old man underwent elective splenectomy for symptomatic splenomegaly at an outside hospital and developed postoperative splenic bed hemorrhage requiring percutaneous drainage. Pathology revealed extramedullary hematopoiesis and bone marrow biopsy showed evidence ofJAK-2 positive primary myelofibrosis. He was readmitted with hypoxic respiratory failure and transferred to our hospital for further care. Upon transfer, he had significant thrombocytosis (1,257,000/mcL from 57,000/mcL two weeks earlier), a hemoglobin of 9 mg/dL, and a WBC count of 4000/mcL with normal differential. CT angiogram ruled out pulmonary embolism, but revealed a new moderate-size left pleural effusion and a gas-containing multiloculated fluid collection in the splenic bed measuring 8 x 7 x 5 cm. Intravenous vancomycin and piperacillin/tazobactam were initiated. He underwent successful CT guided placement of a pigtail catheter, immediately draining 35cc of purulent fluid. A sinogram, 24 hours later, demonstrated patent drain positioned in the largest component of the multiloculated abscess. He underwent three successive thoracenteses for reaccumulating left sided effusion, demonstrating culture-negative exudate. Intraabdominal fluid cultures grew MSSA, Finegoldia magna and Propionibacterium avidum and antibiotics were tailored to once-daily ertapenem. Clinically he appeared to improve, however platelet counts continued to increase despite maximal doses of hydroxyurea. When platelet counts reached 2,144,000/mcL, apheresis was performed and platelet counts decreased to 751,000/mcL. Given the lack of correlation between his seemingly improving clinical picture and laboratory data, there was concern for an occult, uncontrolled, intraabdominal infection. A repeat sinogram showed uncontrolled abscess and a possible fistulous communication with the colon. Surgical intervention was debated (very high risk) and the patient chose conservative management. The pigtail catheter was repositioned within the multiloculated abscess. He subsequently improved with percutaneous drainage and IV antimicrobials.

Discussion: This case illustrates important signs of ongoing inflammation, on both the local and systemic level. Sympathetic pleural effusions are exudative in nature, and occur ipsilateral to an inflammatory intra-abdominal process. Resolution of the underlying inflammation will, in most cases, lead to resolution of the effusion. The worsening post-splenectomy thrombocytosis, initially thought to reflect myelofibrosis-driven extra-medullary hematopoiesis, was discrepant to the patient’s apparent clinical improvement and raised alarm for an inappropriately controlled abscess.

Conclusions: This case highlights the importance of careful clinical diagnosis and interpretation of data. Questioning the reason for worsening thrombocytosis, in an otherwise well appearing patient, prompted further imaging and appropriate changes in management.