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Lokuhetty N, Philip MT, Paynter JA, Owen AR. A case report of successful splenic artery embolization for atraumatic splenic rupture secondary to Epstein Barr virus infection in a haemodynamically unstable patient. Radiol Case Rep 2024; 19:1970-1974. [PMID: 38434780 PMCID: PMC10909597 DOI: 10.1016/j.radcr.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
Splenic rupture in haemodynamically unstable patients has traditionally been managed with splenectomy. This case report discusses the successful management of atraumatic splenic rupture, a rare but life-threatening complication of Epstein-Barr virus (EBV) infection, in a hemodynamically unstable patient. The patient, diagnosed with infectious mononucleosis (IM) secondary to EBV, presented with severe abdominal pain and a syncopal episode. Imaging revealed an American Association for the Surgery of Trauma (AAST) grade III splenic injury, which was subsequently upgraded to a grade IV injury on repeat imaging. The patient's condition deteriorated even with initial resuscitation, leading to splenic angioembolization. The procedure was successful and the patient was discharged after 5 days. This case highlights the efficacy of splenic artery embolization (SAE) in haemodynamically unstable patients with atraumatic splenic rupture, particularly in centers with interventional radiology resources, offering an alternative to splenectomy and its associated complications.
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Toti JMA, Gatti B, Hunjan I, Kottanattu L, Faré PB, Renzi S, Bianchetti MG, Milani GP, Lava SAG, Camozzi P. Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review. Swiss Med Wkly 2023; 153:40081. [PMID: 37245117 DOI: 10.57187/smw.2023.40081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Epstein-Barr virus (EBV), also known as human herpesvirus 4, is one of the most common pathogenic viruses in humans. EBV mononucleosis always involves the spleen and as such it predisposes to splenic rupture, often without a trauma, and splenic infarction. Nowadays the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections. METHODS To characterise these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible articles were those describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis. RESULTS In the literature, we found 171 articles published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (n = 139) of cases occurred within three weeks of the onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery splenic rupture score, which was retrospectively calculated, and surgical management: splenectomy in 84% (n = 44) of cases with a severe score and in 58% (n = 70) of cases with a moderate or minor score (p = 0.001). The mortality rate of splenic rupture was 4.8% (n = 9). In splenic infarction, an underlying haematological condition was observed in 21% (n = 6) of cases. The treatment of splenic infarction was always conservative without any fatal outcomes. CONCLUSIONS Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a pre-existing haematological condition.
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Affiliation(s)
- Johannes M A Toti
- Department of Surgery and Transplantation, University Hospital Zurich Zurich, Switzerland
| | - Beatrice Gatti
- Family medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Isabella Hunjan
- Family medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Lisa Kottanattu
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Pietro B Faré
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Samuele Renzi
- Division of Hematology and Oncology, CHUL-Laval, Quebec City, Canada
- Department of Pediatrics, Laval University, Quebec City, Canada
| | - Mario G Bianchetti
- Family medicine, Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- Heart Failure and Transplantation, Department of Pediatric Cardiology, Great Ormond Street Hospital, London, United Kingdom
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Spontaneous splenic rupture secondary to Epstein-Barr Virus-induced infectious mononucleosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Uthayakumar A, Harrington D. Spontaneous splenic rupture complicating primary varicella zoster infection: a case report. BMC Res Notes 2018; 11:334. [PMID: 29789000 PMCID: PMC5964893 DOI: 10.1186/s13104-018-3430-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 05/10/2018] [Indexed: 11/24/2022] Open
Abstract
Background Primary varicella zoster virus (VZV) infection is a common illness, predominantly affecting children. Its course is typically benign, although severe complications have been described. Splenic rupture is an extremely rare and potentially fatal complication of primary VZV infection, with only a handful of cases reported in the literature. Case Presentation A 32-year-old Romanian man with no significant past medical history, presented with a 2 day history of sudden onset, worsening generalised abdominal pain and a 1 day history of vomiting. The following day he developed fevers and a generalised widespread erythematous rash consisting of clusters of macules, papules and vesicles at different stages of development. There was no history of sore throat, coryza, arthralgia, myalgia, cough, shortness of breath, weight loss, or night sweats. There was no recent illness and no history of trauma. CT abdomen showed splenic rupture with intra-abdominal haemorrhage. Admission bloods showed anaemia and thrombocytopenia, with haemoglobin 110 g/l and platelets 78 × 109/l. Viral PCR of vesicle fluid from the rash was positive for VZV DNA confirming the clinical diagnosis of primary varicella zoster infection. Viral serology also confirmed recent infection. He was haemodynamically resuscitated, and underwent laparotomy and splenectomy. He was commenced on IV acyclovir and completed a 5 day course. Prior to discharge he was commenced on recommended splenectomy secondary prevention treatment. Conclusion There are several reported complications of varicella infection, more commonly in the immunocompromised population. Spontaneous splenic rupture is an unusual complication of primary VZV infection. Here we report the sixth known case in the literature. Splenic rupture should be considered in cases of primary varicella in young adults presenting with abdominal pain.
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Affiliation(s)
- Aarthy Uthayakumar
- University College London Hospitals NHS Trust, 235 Euston Road, London, UK.
| | - David Harrington
- Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
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Splenic rupture in infectious mononucleosis: A systematic review of published case reports. Injury 2016; 47:531-8. [PMID: 26563483 DOI: 10.1016/j.injury.2015.10.071] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Infectious mononucleosis (IM) is a common viral illness that predominantly causes sore throat, fever and cervical lymphadenopathy in adolescents and young adults. Although usually a benign, self-limiting disease, it is associated with a small risk of splenic rupture, which can be life-threatening. It is common practice therefore to advise avoiding vigorous physical activity for at least 4-6 weeks, however this is not based on controlled trials or national guidelines. We reviewed published case reports of splenic rupture occurring in the context of IM in an attempt to ascertain common factors that may predict who is at risk. METHOD A search of MEDLINE and EMBASE databases was performed for case reports or series published between 1984 and 2014. In total, 52 articles or abstracts reported 85 cases. Data was extracted and compiled into a Microsoft Excel(®) spreadsheet. RESULTS The average patient age was 22 years, the majority (70%) being male. The average time between onset of IM symptoms and splenic rupture was 14 days, with a range up to 8 weeks. There was a preceding history of trauma reported in only 14%. Abdominal pain was the commonest presenting complaint of splenic rupture, being present in 88%. 32% were successfully managed non-operatively, whereas 67% underwent splenectomy. Overall mortality was 9%. CONCLUSIONS AND RECOMMENDATIONS From our data, it appears that men under 30 within 4 weeks of symptom onset are at highest risk of splenic rupture, therefore particular vigilance in this group is required. As cases have occurred up to 8 weeks after the onset of illness, we would recommend avoidance of sports, heavy lifting and vigorous activity for 8 weeks. Should the patient wish to return to high risk activities prior to this, an USS should be performed to ensure resolution of splenomegaly. The majority of cases reviewed had no preceding trauma, although previous studies have suggested this may be so minor as to go unnoticed by the patient. It is therefore prudent to warn patients about the symptoms of splenic rupture to ensure prompt presentation and minimise treatment delay rather than focusing purely on activity limitation.
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Sergent SR, Johnson SM, Ashurst J, Johnston G. Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:774-7. [PMID: 26516137 PMCID: PMC4631128 DOI: 10.12659/ajcr.893919] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/24/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is a common infection with worldwide distribution; more than 90% of people have been infected by adulthood. One of the most feared, albeit rare, complications, occurring in less than 0.5% of those infected, is splenic injury or rupture. CASE REPORT A febrile 15-year-old male presented to the emergency department with the chief compliant of headache, neck pain, and upper shoulder pain. He did not recall any specific traumatic injury. His abdomen was soft, nondistended, and was tender in the right and left lower quadrants. Right lower quadrant ultrasound demonstrated non-visualization of the appendix, moderate right lower quadrant free fluid, and positive McBurney's sign. CT of the abdomen and pelvis was ordered, which demonstrated moderate splenomegaly, with findings compatible with laceration through the anterior aspect of the spleen, with moderate hemoperitoneum. Monospot was negative and EBV panel demonstrated IGG negative, IGM positive, and, IGG negative. The patient was transferred to interventional radiology for a splenic angiogram and proximal splenic artery embolization. The angiogram demonstrated grade 3 laceration with moderate hemoperitoneum and no active extravasation or evidence of pseudoaneurysm. The patient was admitted and made a prompt recovery without any other sequelae. CONCLUSIONS The presentation of splenic injury or rupture can vary; the patient may complain of abdominal pain or left upper quadrant pain, may exhibit referred left shoulder pain when the LUQ is palpated (Kehr's Sign), or may exhibit hemodynamic instability. Given the spectrum of non-specific symptoms, diagnosing EBV-induced splenic laceration can be difficult.
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Affiliation(s)
- Shane R. Sergent
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA, U.S.A
- Clinical Faculty, Michigan State University College of Osteopathic Medicine, Michigan State University, East Lansing, MI, U.S.A
| | - Sophia M. Johnson
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA, U.S.A
| | - John Ashurst
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA, U.S.A
| | - Greg Johnston
- Department of Emergency Medicine, Conemaugh Memorial Hospital, Johnstown, PA, U.S.A
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Abstract
A 15-year-old previously healthy girl presented in full arrest after 1 week of flu-like symptoms, recent diagnosis of infectious mononucleosis, and 1 day of abdominal pain. There was no history of trauma. Focused assessment with sonography for trauma examination showed free fluid in the abdomen. The patient died despite aggressive resuscitative management and emergency laparotomy with splenectomy, which showed grade V splenic laceration. Infectious mononucleosis is a common viral illness of adolescence. Spontaneous splenic rupture is a rare but potentially fatal complication. Anticipatory guidance about the importance of seeking medical care if abdominal pain develops during infectious mononucleosis is crucial to early diagnosis and intervention in the case of rupture. We discuss the current literature surrounding the outpatient follow-up of splenomegaly associated with infectious mononucleosis, as well as current practice and treatment options when rupture occurs.
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López-Tomassetti Fernández EM, Delgado Plasencia L, Arteaga González IJ, Carrillo Pallares A, Hernández Siverio N. [Atraumatic rupture of the spleen: experience of 10 cases]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 30:585-91. [PMID: 18028854 DOI: 10.1157/13112586] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The most common cause of splenic rupture is trauma. Less frequently the spleen ruptures due to an ongoing hematologic, infectious or tumoral disease (pathologic rupture). We present a series of 10 patients with atraumatic splenic rupture: in seven patients there was a pathologic rupture. Two of the remaining three patients with spontaneous rupture were morbidly obese; this association has not previously been reported. The present review discusses the etiology, pathogenesis and optimal treatment of this entity.
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Szokó M, Matolcsy A, Kovács G, Simon G. [Spontaneous splenic rupture as a complication of symptom-free infections mononucleosis]. Orv Hetil 2007; 148:1381-4. [PMID: 17631473 DOI: 10.1556/oh.2007.28094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Splenic rupture is a rare complication of infectious mononucleosis. Although it occurs only in 0.1%-0.5% of cases, splenic rupture remains the most common fatal complication of the disease. Mononucleosis related spontaneous rupture of the spleen without any other characteristic symptoms of the disease is extremely unusual, and threatens with fatal outcome due to its rare and unexpected occurrence. The authors report the case of a 16-year-old boy who needed splenectomy following a spontaneous rupture of the spleen. Serological tests proved an acute Epstein-Barr virus infection in the background but without any signs or symptoms of infectious mononucleosis. The diagnosis and treatment of this infection related to spleen ruptures are also discussed.
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Affiliation(s)
- Márta Szokó
- Fejér Megyei Szent György Kórház Csecsemo- és Gyermekosztály Székesfehérvár Seregélyesi út 3 8000.
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Abstract
The management of any surgical condition in a haemophilia patient is a challenging problem for the surgeon. It is particularly difficult if the patient presents in extremis, with no apparent cause for their collapse. We report a case of successful management of spontaneous splenic rupture in a severe haemophiliac, and review the literature associated with this unusual condition.
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Bandiera G, Poulin E. Unusual case of acute onset abdominal pain: uses and limitations of medical imaging. CAN J EMERG MED 2003; 5:263-7. [PMID: 17472770 DOI: 10.1017/s1481803500008472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
ABSTRACT
A 28-year-old male with atraumatic abdominal pain and transient hypotension was assessed using bedside emergency department (ED) ultrasonography and contrast enhanced helical computed tomography (CT). Both tests revealed free intraperitoneal fluid, but neither detected a splenic defect. The patient subsequently underwent splenectomy for a ruptured spleen. His serology for typical viral causes was negative. This article discusses spontaneous splenic rupture, the role of imaging in diagnosis, and the limitations of ED ultrasound and contrast enhanced helical CT.
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