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Putukian M, McGrew CA, Benjamin HJ, Hammell MK, Hwang CE, Ray JW, Statuta SM, Sylvester J, Wilson K. American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation. Clin J Sport Med 2023:00042752-990000000-00124. [PMID: 37186809 DOI: 10.1097/jsm.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/27/2023] [Indexed: 05/17/2023]
Abstract
ABSTRACT Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.
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Affiliation(s)
| | - Christopher A McGrew
- Department of Family and Community Medicine, Department of Orthopedics and Rehabilitation, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Holly J Benjamin
- Department of Orthopaedic Surgery, Rehabilitation Medicine and Pediatrics, University of Chicago; Chicago, IL
| | - Mary Kitazono Hammell
- Princeton Radiology Associates, University of Pennsylvania; Philadelphia, Pennsylvania
| | - Calvin E Hwang
- Department of Orthopaedic Surgery, Stanford University School of Medicine; Stanford, California
| | | | - Siobhan M Statuta
- Department of Family Medicine, Department of Physical Medicine and Rehabilitation, University of Virginia; Charlottesville, Virginia
| | - Jillian Sylvester
- Department of Orthopaedics, University of North Carolina School of Medicine; Chapel Hill, North Carolina; and
| | - Kristina Wilson
- Department of Child Health, University of Arizona College of Medicine; Phoenix, Arizona
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Rastogi V, Singh D, Tekiner H, Ye F, Mazza JJ, Yale SH. Abdominal Physical Signs and Medical Eponyms: Part II. Percussion and Auscultation, 1924-1980. Clin Med Res 2020; 18:102-108. [PMID: 31324737 PMCID: PMC7428204 DOI: 10.3121/cmr.2018.1429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Percussion and auscultation are derived from the Latin words to touch and hear, respectively. Covered are abdominal percussion signs and ausculatory signs discovered from 1924 to 1980. Signs ascribed as medical eponyms pay homage to these physicians who provided new and unique insights into disease. DATA SOURCES PubMed, Medline, online Internet word searches, textbooks, and references from other source text. PubMed was searched using the Medical Subject Heading (MeSH) of the name of the eponyms and text words associated with the sign. CONCLUSION Many of these signs have been discarded because of modern imaging and diagnostic techniques. When combined with a high clinical suspicion, positive results using percussion combined with palpation is a useful bedside technique in detecting splenic enlargement. Thus, some of these maneuvers remain important bedside techniques that skilled practitioners should master, and along with a meaningful history, provide relevant information to diagnosis. It is through learning about these signs that we gain a sense of humility on the difficulty physicians faced prior to the advent of techniques that now allow us an easier way to visualize and diagnose the underlying disease processes.
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Affiliation(s)
- Vaibhav Rastogi
- University of Central Florida College of Medicine, Graduate Medical Education, 6850 Lake Nona Blvd, Orlando, Florida, USA
| | - Devina Singh
- University of Florida, Department of Medicine, 2000 SW Archer Rd, Gainesville, Florida, USA
| | - Halil Tekiner
- Erciyes University School of Pharmacy, Department of the History of Pharmacy and Ethics, Talas, Kayseri 38280 Turkey
| | - Fan Ye
- University of Central Florida College of Medicine, Graduate Medical Education, 6850 Lake Nona Blvd, Orlando, Florida, USA
| | - Joseph J Mazza
- Marshfield Clinic Research Institute, 1000 North Oak Avenue, Marshfield, Wisconsin, USA
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Yoshida K, Kurihara I, Fukuchi T, Sugawara H. Acute splenic infarction presenting as an unusual manifestation of essential thrombocythaemia with normal platelet count. BMJ Case Rep 2019; 12:12/7/e229387. [PMID: 31272993 DOI: 10.1136/bcr-2019-229387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Essential thrombocythaemia (ET) is characterised by elevated platelet count by a clonal stem cell disorder of megakaryocytes. Although thrombosis is a common complication of ET, splenic infarction (SI) is extremely rare. Here, we present the case of a 31-year-old Japanese man who presented with sudden-onset severe pain at the left hypochondrium on the day before admission. Enhanced abdominal CT revealed SI. The laboratory test results revealed a normal platelet count (439×109/L). Subsequently, the patient was diagnosed with ET because the platelet count gradually increased to 50.0×104/μL, and JAK2 V617F mutation was identified. Accordingly, low-dose aspirin was initiated, and no thrombotic episode occurred. Nevertheless, 6 months postdischarge, the platelet count gradually increased to >650 × 109/L, and anagrelide was initiated. This case demonstrates an unusual complication of acute SI due to ET under the rare situation of the normal platelet count.
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Affiliation(s)
- Katsuyuki Yoshida
- Division of General Medicine, Department of Comprehensive Medicine 1, Jichi Ika Daigaku Fuzoku Saitama Iryo Center, Saitama, Japan
| | - Ibuki Kurihara
- Division of General Medicine, Department of Comprehensive Medicine 1, Jichi Ika Daigaku Fuzoku Saitama Iryo Center, Saitama, Japan
| | - Takahiko Fukuchi
- Division of General Medicine, Department of Comprehensive Medicine 1, Jichi Ika Daigaku Fuzoku Saitama Iryo Center, Saitama, Japan
| | - Hitoshi Sugawara
- Division of General Medicine, Department of Comprehensive Medicine 1, Jichi Ika Daigaku Fuzoku Saitama Iryo Center, Saitama, Japan
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Vasconcellos LDS, Petroianu A, Romeiro JR, Tavares Junior WC, Resende V. Correlation between the values of circulating blood elements with the size of spleen in the presence of schistosomal splenomegaly. Acta Cir Bras 2019; 33:1103-1109. [PMID: 30624516 DOI: 10.1590/s0102-865020180120000008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/25/2018] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To evaluate a possible relationship between the size of the spleen and values of circulating blood elements in patients with schistosomatic splenomegaly. METHODS ixty one patients with hepatosplenic schistosomiasis mansoni underwent a clinical exam and peripheral venous blood was collected for a hemogram. The erythrocyte, hemoglobin, hematocrit, leukocyte, and platelet values were determined. All patients underwent abdominal ultrasound to measure the spleen. The hematological test results were compared to the size of the spleen. RESULTS The size of the spleen varied from 14.0 to 28.4 (19.9 ± 3.7) cm according to the ultrasound image. Thrombocytopenia was observed 58 (95%) patients, leukopenia in 55 (90%) patients, and anemia in 32 (52.4%) patients. Leukopenia was proportional to splenomegaly. CONCLUSION Schistosomal splenomegaly leads to leukopenia in direct proportion to the size of the spleen.
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Affiliation(s)
- Leonardo de Souza Vasconcellos
- PhD, Associate Professor, Complementary Propaedeutics Department, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte-MG, Brazil. Scientific, intellectual, conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; statistical analysis; manuscript preparation and writing
| | - Andy Petroianu
- PhD, Full Professor, Department of Surgery, Faculty of Medicine, UFMG, Researcher 1B CNPq, Belo Horizonte-MG, Brazil.Scientific, intellectual, conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; manuscript preparation and writing; critical revision; final approval
| | - Juliana Ribeiro Romeiro
- PhD, School of Medicine, UFMG, Belo Horizonte-MG, Brazil. Acquisition of data, technical procedures
| | | | - Vivian Resende
- PhD, Associate Professor, Department of Surgery, School of Medicine, UFMG, Belo Horizonte-MG, Brazil. Scientific, intellectual, conception and design of the study; acquisition, analysis and interpretation of data; technical procedures; statistical analysis; manuscript preparation and writing; critical revision
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Cessford T, Meneilly GS, Arishenkoff S, Eddy C, Chen LYC, Kim DJ, Ma IWY. Comparing Physical Examination With Sonographic Versions of the Same Examination Techniques for Splenomegaly. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1621-1629. [PMID: 29219201 DOI: 10.1002/jum.14506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To determine whether sonographic versions of physical examination techniques can accurately identify splenomegaly, Castell's method (Ann Intern Med 1967; 67:1265-1267), the sonographic Castell's method, spleen tip palpation, and the sonographic spleen tip technique were compared with reference measurements. METHODS Two clinicians trained in bedside sonography patients recruited from an urban hematology clinic. Each patient was examined for splenomegaly using conventional percussion and palpation techniques (Castell's method and spleen tip palpation, respectively), as well as the sonographic versions of these maneuvers (sonographic Castell's method and sonographic spleen tip technique). Results were compared with a reference standard based on professional sonographer measurements. RESULTS The sonographic Castell's method had greater sensitivity (91.7% [95% confidence interval, 61.5% to 99.8%]) than the traditional Castell's method (83.3% [95% confidence interval, 51.6% to 97.9%]) but took longer to perform [mean ± SD, 28.8 ± 18.6 versus 18.8 ± 8.1 seconds; P = .01). Palpable and positive sonographic spleen tip results were both 100% specific, but the sonographic spleen tip method was more sensitive (58.3% [95% confidence interval, 27.7% to 84.8%] versus 33.3% [95% confidence interval, 9.9% to 65.1%]). CONCLUSIONS Sonographic versions of traditional physical examination maneuvers have greater diagnostic accuracy than the physical examination maneuvers from which they are derived but may take longer to perform. We recommend a combination of traditional physical examination and sonographic techniques when evaluating for splenomegaly at the bedside.
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Affiliation(s)
- Tara Cessford
- Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graydon S Meneilly
- Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shane Arishenkoff
- Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Eddy
- Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luke Y C Chen
- Departments of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel J Kim
- Departments of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Irene W Y Ma
- Department of Medicine and W21C Research and Innovation Center, University of Calgary, Calgary, Alberta, Canada
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Abstract
OBJECTIVE To determine appropriate management of the active individual with infectious mononucleosis (IM), including issues of diagnosis, the determination of splenomegaly, and other measures of disease status, the relationship of the disease to chronic fatigue syndrome (CFS), and the risks of exercise at various points in the disease process. DATA SOURCES An Ovid/MEDLINE search (January 1996-June 2015) was widely supplemented by "similar articles" found in Ovid/MEDLINE and PubMed, reference lists, and personal files. MAIN RESULTS Clinical diagnoses of IM are unreliable. Traditional laboratory indicators (lymphocytosis, abnormal lymphocytes, and a heterophile-positive slide test) can be supplemented by more sensitive and more specific but also more costly Epstein-Barr antigen determinations. Clinical estimates of splenomegaly are fallible. Laboratory determinations, commonly by 2D ultrasonography, must take account of methodology, the formulae used in calculations and the individual's body size. The SD of normal values matches the typical increase of size in IM, but repeat measurements can help to monitor regression of the disease. The main risks to the athlete are spontaneous splenic rupture (seen in 0.1%-0.5% of patients and signaled by acute abdominal pain) and progression to chronic fatigue, best avoided by 3 to 4 weeks of restricted activity followed by graded reconditioning. A full recovery of athletic performance is usual with 2 to 3 months of conservative management. CONCLUSIONS Infectious mononucleosis is a common issue for young athletes. But given accurate diagnosis and the avoidance of splenic rupture and progression to CFS through a few weeks of restricted activity, long-term risks to the health of athletes are few.
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Stewart KR, Derck AM, Long KL, Learman K, Cook C. Diagnostic accuracy of clinical tests for the detection of splenomegaly. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/1743288x13y.0000000081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Affiliation(s)
- John Turner
- Department of Family Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
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Blaylock JM, Decker CF. Common infections in the collegiate athlete. Dis Mon 2010; 56:422-35. [PMID: 20621216 DOI: 10.1016/j.disamonth.2010.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jason M Blaylock
- Infectious Diseases Service, Department of Internal Medicine, Walter Reed Medical Center, Washington, DC, USA
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Dhingra B, Sharma S, Mishra D, Kumari R, Pandey RM, Aggarwal S. Normal values of liver and spleen size by ultrasonography in Indian children. Indian Pediatr 2009; 47:487-92. [PMID: 19736366 DOI: 10.1007/s13312-010-0090-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 06/03/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To establish normative data for the ultrasonographic measurement of liver and spleen size in healthy Indian children. SETTING Tertiary-care pediatric teaching hospital. DESIGN Cross-sectional, hospital-based study. PARTICIPANTS 597 healthy children between the ages of 1 month to 12 years. MEASUREMENTS Ultrasonographic evaluation for the assessment of liver and spleen size. These were correlated with the age, sex, height/length and weight of the participants. RESULTS Normal liver and spleen length and range were obtained sonographically. The liver and spleen length significantly correlated highly with the height/length of the subjects (P=0.0001). CONCLUSIONS The study provides the normal values of liver and spleen size by ultrasonography in healthy Indian children.
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Affiliation(s)
- Bhavna Dhingra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalaya (Maulana Azad Medical College), Geeta Colony, Delhi, India
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Abstract
Infectious mononucleosis (IM) is a common medical condition that afflicts thousands of young athletes each year. Despite the self-limited nature of this disorder, the variability of the clinical presentation and the rare risk of splenic rupture routinely present sports medicine clinicians with difficult return-to-play decisions. Currently there are no evidence-based guidelines regarding the management of the athlete with IM. This review discusses the available research data pertaining to the management of IM in young athletes and develops questions for future clinical research.
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Silva LCS, Pereira ACF, Queiroz LC, Andrade LM, Antunes CMF, Lambertucci JR. Disagreement between ultrasound and magnetic resonance imaging in the identification of schistosomal periportal fibrosis. Mem Inst Oswaldo Cruz 2006; 101 Suppl 1:279-82. [PMID: 17308782 DOI: 10.1590/s0074-02762006000900043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 06/26/2006] [Indexed: 11/21/2022] Open
Abstract
Abdominal ultrasound (US) has been widely used in the evaluation of patients with schistosomiasis mansoni. It represents an important indirect method of diagnosis and classification of the disease, and it has also been used as a tool in the evaluation of therapeutic response and regression of fibrosis. We describe the case of a man in whom US showed solid evidence of schistosomal periportal fibrosis and magnetic resonance imaging revealed that periportal signal alteration corresponded to adipose tissue which entered the liver together with the portal vein.
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Affiliation(s)
- Luciana C S Silva
- Serviço de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Alfredo Balena 190, 30130-100 Belo Horizonte, MG, Brazil.
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Joshua AM, Celermajer DS, Stockler MR. Beauty is in the eye of the examiner: reaching agreement about physical signs and their value. Intern Med J 2005; 35:178-87. [PMID: 15737139 DOI: 10.1111/j.1445-5994.2004.00795.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite advances in other areas, evidence-based medicine is yet to make substantial inroads on the standard medical physical examination. We have reviewed the evidence about the accuracy and reliability of the physical examination and common clinical signs. The physical examination includes many signs of marginal accuracy and reproducibility. These may not be appreciated by clinicians and could adversely affect decisions about treatment and investigations or the teaching and examination of students and doctors-in-training. We provide a selected summary of the reliability and accuracy as well as important messages of key findings in the physical examination.
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Affiliation(s)
- A M Joshua
- Department of Medical Oncology, Sydney Cancer Centre, Sydney, New South Wales, Australia.
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Lambertucci JR, Silva LCDS, Andrade LM, de Queiroz LC, Pinto-Silva RA. Magnetic resonance imaging and ultrasound in hepatosplenic schistosomiasis mansoni. Rev Soc Bras Med Trop 2004; 37:333-7. [PMID: 15334268 DOI: 10.1590/s0037-86822004000400009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report the findings of abdominal ultrasound and magnetic resonance imaging observed in a patient with advanced schistosomiasis mansoni. A 25-year-old man with hepatosplenic schistosomiasis and variceal bleeding confirmed by upper endoscopy was submitted to abdominal ultrasound and magnetic resonance imaging. During surgery for portal hypertension, a liver biopsy was taken and the diagnosis of Symmers' fibrosis was confirmed. magnetic resonance imaging scans gave more precise information about the gallbladder, periportal thickening and abdominal venous system than did the ultrasound.
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Affiliation(s)
- José Roberto Lambertucci
- Serviço de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
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Gerspacher-Lara R, Pinto-Silva RA, Serufo JC, Rayes AA, Drummond SC, Lambertucci JR. Splenic palpation for the evaluation of morbidity due to schistosomiasis mansoni. Mem Inst Oswaldo Cruz 1999; 93 Suppl 1:245-8. [PMID: 9921361 DOI: 10.1590/s0074-02761998000700045] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study was undertaken to determine the accuracy of splenic palpation for the diagnosis of splenomegaly, and to determine whether the frequency of individuals with a palpable spleen in an endemic area can be considered as an index of morbidity of schistosomiasis. For the clinical diagnosis of splenomegaly, two criteria have been tested: (A) presence of a palpable spleen and (B) presence of a palpable spleen whose border could be felt more than 4 cm below the costal margin. In an area of high prevalence of the disease (66.3%) 285 individuals aged 18 years or more have been submitted to abdominal ultrasonography and physical examination. Splenomegaly was defined as a splenic length greater than 120 mm by ultrasound and the sensitivity, specificity, positive and negative predictive values of criterion A were 72.2%, 90.5%, 35.1% and 97.8%. The values for criterion B were 27.8%, 98%, 50% and 95%, respectively. In an non endemic area, 517 individuals were submitted to the same protocol and 22 individuals had a palpable spleen, but no patient fulfilled criterion B for splenomegaly, and only one met the ultrasonographic criterion for splenomegaly. The authors concluded that abdominal palpation is a poor method for the diagnosis of splenomegaly.
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Affiliation(s)
- R Gerspacher-Lara
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
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Lambertucci JR, Gerspacher-Lara R, Pinto-Silva RA, Barbosa MM, Teixeira R, Barbosa HF, Serufo JC, Rezende DF, Drummond SC, Rayes AA. [The Queixadinha Project: morbidity and control of schistosomiasis in an endemic area in the northeast of Minas Gerais, Brazil]. Rev Soc Bras Med Trop 1996; 29:127-35. [PMID: 8713604 DOI: 10.1590/s0037-86821996000200005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
In an endemic area for schistosomiasis in the northeast of the state of Minas Gerais in Brazil 516 individuals have been submitted to clinical and laboratory examination, ultrasonography of the abdomen and dopplerecocardiography in order to define the morbidity of schistosomiasis before and after treatment. A high prevalence of schistosomiasis (66.3%) and of severe disease (9.5% with palpable spleens) were recorded. Ultrasonography classified liver periportal fibrosis as light (19.4%), moderate (27.6%) and intense (6.8%), and 46.0% presented no periportal fibrosis. Twenty one out of the 53 individuals (39.6%) with palpable spleens did not present liver fibrosis on ultrasound. Periportal lymph nodes were described in 33.8% of the population and anti-KLH antibodies were found in the serum of 40.7%. Urinary alterations compatible with the glomerulopathy of schistosomiasis were observed in 4.5% of the population, and 11.7% of the individuals examined by dopplerecocardiography had pulmonary hypertension. Twelve months after treatment for schistosomiasis the prevalence of the disease dropped from 66.3% to 25.0%. In Queixadinha, a profile of the morbidity of schistosomiasis has just been established.
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Affiliation(s)
- J R Lambertucci
- Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte
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Abstract
There are three percussion sounds, which are easily distinguishable by objective measures: tympany (heard with percussion over the intestines), resonance (heard over the normal lung), and dullness (heard over the liver or thigh). The percussion sound that is produced reflects the ease with which the body wall vibrates, which in turn is influenced by many variables, including the strength of the stroke, the condition and state of the body wall, and the underlying organs. Underlying organs or disease may cause dullness to occur at distant sites. There is good interobserver agreement among clinicians with regard to calling a particular percussion sound dull, resonant, or hyperresonant. In contrast, there is very poor interobserver agreement among clinicians using percussion to measure the span of a particular organ. The use of comparative percussion can detect most large pleural effusions, but this method is able to detect only a few pneumonias. Shifting dullness is a reliable and fairly accurate sign for the detection of ascites. Both of these techniques can still be recommended after a review of the literature. Topographic percussion (e.g., using percussion to locate the heart, liver, and spleen borders or dimensions) has poor reproducibility, is significantly inaccurate in many patients, and has little clinical utility; it should be abandoned. Its fundamental principle--that sound waves penetrate only several centimeters of tissue, resulting in a note reflecting abnormalities only in this layer of tissue--is incorrect. Auscultatory percussion offers no advantage over conventional percussion, with the possible exception of auscultatory percussion of the shoulder. Auscultatory percussion should be abandoned as a bedside diagnostic technique.
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Affiliation(s)
- S R McGee
- Seattle Veterans Affairs Medical Center, Washington, USA
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Tamayo SG, Rickman LS, Mathews WC, Fullerton SC, Bartok AE, Warner JT, Feigal DW, Arnstein DG, Callandar NS, Lyche KD. Examiner dependence on physical diagnostic tests for the detection of splenomegaly: a prospective study with multiple observers. J Gen Intern Med 1993; 8:69-75. [PMID: 8441078 DOI: 10.1007/bf02599986] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the reliability and validity of various physical diagnostic techniques (including three methods of palpation and three methods of percussion) in detecting ultrasonographically identified splenomegaly. DESIGN Prospective, double-blind study. SETTING University hospital. PATIENTS Twenty-seven hospitalized male patients with suspected human immunodeficiency virus (HIV) infection. INTERVENTIONS Three methods of palpation (bimanual, ballottement, and palpation from above) and three methods of percussion (as described by Nixon, Castell, and Barkun et al.) were performed on each patient by eight examiners. Splenic ultrasonography was performed within 96 hours of admission. MEASUREMENTS AND MAIN RESULTS The prevalence of splenomegaly by ultrasonography (defined as a spleen > or = 13 cm on the longitudinal scan) in this population was 33.3%. The sensitivity and specificity of each method of palpation and percussion varied by examiner. The ranges of sensitivity across examiners for the three methods of palpation and the three methods of percussion were 0%-64.3% and 7.7%-75%, respectively. The ranges of specificity across examiners for the three methods of palpation and the three methods of percussion were 50%-100% and 60%-100%, respectively. Likelihood ratios pooled across observers revealed that for palpation, palpation from above, and percussion, Castell's method had the highest likelihood ratios [LR = 2.66 and 1.97, respectively; 95% CI = 1.52-4.64 and 1.22-3.19, respectively]. A combination of tests (either palpation or percussion) increased the diagnostic accuracy. CONCLUSION Physical diagnostic techniques for the detection of splenomegaly are relatively insensitive but specific. In this study there was high interobserver variability, which did not appear to be associated to the level of experience. Combining tests increases diagnostic accuracy.
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Affiliation(s)
- S G Tamayo
- Department of Biology, University of California, San Diego
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