Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: a case report and review of the literature

Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review

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.

A Rare Case of Brucellosis With Spontaneous Splenic Rupture Presenting as an Acute Abdomen

Brucellosis is a common zoonotic infection worldwide caused by the bacterial species Brucella. It has a wide range of presentations from asymptomatic infection to multisystem involvement. Splenomegaly is seen in around 30-60% of cases, however, atraumatic spontaneous splenic rupture is extremely rare. We present a case of a 45-year-old man who presented with acute left upper quadrant pain and fever of five days duration without a history of antecedent trauma. He was hemodynamically stable with examination revealing left upper quadrant tender palpable mass. Ultrasonography followed by computed tomography revealed subcapsular hematoma with perisplenic and perihepatic free fluid. Viral markers (hepatitis B and C, cytomegalovirus {CMV}, Epstein-Barr virus {EBV}, HIV, and dengue) were negative. The autoimmune profile was negative. Brucella serum agglutination test was positive (1: 640) and blood cultures grew Brucella melitensis. He was managed conservatively for splenic hematoma and received one unit blood transfusion and treatment with combination of antibiotics (rifampicin and doxycycline) for brucella for six weeks. On follow-up, the patient reported no further complications. Spontaneous splenic rupture is a clinical rarity and should be considered in patients presenting with acute abdomen and suspected infective, neoplastic, and inflammatory pathology. Spontaneous splenic rupture in acute brucellosis requires prompt clinical recognition and immediate anti-Brucella therapy to prevent the catastrophic progression.

Atraumatic splenic rupture in a child with COVID 19

Background

The majority of children with COVID-19 have only minor symptoms or none at all. COVID-19, on the other hand, can cause serious illness in some children, necessitating hospitalization, intensive care, and invasive ventilation. Many studies have revealed that SARS-CoV-2 affects not only the respiratory system, but also other vital organs in the body. We report here a child with an atraumatic splenic rupture as the initial and only manifestation of COVID-19.

Case presentation

A 13-year-old boy with clinical signs of acute abdomen, left-sided abdominal pain, and hemodynamic instability was admitted to the PICU in critical condition. His parents denied any trauma had occurred. In addition to imaging tests, a nasopharyngeal swab was taken for COVID-19 testing, which was positive. The thoracic CT scan was normal, whereas the abdominal CT scan revealed hemoperitoneum, splenic rupture, and free fluid in the abdomen.

Conclusions

The spleen is one of the organs targeted by the SARS-CoV-2. Splenic rupture, a potentially fatal and uncommon complication of COVID-19, can be the first and only clinical manifestation of the disease in children. All pediatricians should be aware of the possibility of atraumatic splenic rupture in children with COVID-19.

A Rare Case of Occult Extra-Baudet Period in a Patient With Spontaneous Splenic Rupture

Spontaneous splenic rupture in the extra-Baudet period is a rare phenomenon demanding a high clinical suspicion for diagnosis with prompt treatment. We present a case of a 39-year-old male presenting with left upper abdominal pain following six months after abdominal trauma. The patient underwent imaging studies showing a large subcapsular splenic hematoma with near-total parenchymal displacement and moderate hemoperitoneum. Sequential scans revealed a non-progressive resolving hematoma with no active extravasation. The patient underwent aggressive initial resuscitation followed by successful conservative management and was discharged.

Spontaneous splenic rupture: A rare complication of acute myeloid leukemia. Report of a case

Introduction

Spontaneous rupture of the spleen (SPR) is a rare and severe affection, difficult to diagnose, with multiple causes such as: Infectious and hematologic affections which represent more than half of the cases. Among this subset of patients, acute myeloid leukemia is one of the causes.

Presentation of case

A 48-year-old man undergoing chemotherapy for acute myeloid leukemia presented with acute intense abdominal pain. Computed tomography showed Abdominal CT scan showed a splenic rupture with abundant hemoperitoneum and bilateral pleural effusion. The patient presented hemodynamic instability and was immediately operated, splenectomy were performed.

Discussion

Spontaneous rupture of the spleen usually presents as a severe abdominal syndrome, which may accompany non-specific symptoms.Two signs are suggestive of splenic rupture: Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) and Balance's sign (palpable tender mass in the left upper quadrant. Diagnostic methods of choice are computed tomography andultrasound. The prognosis is depending on the quality of care and the nature of the etiology. Splenectomy remains the cornerstone of the treatment of splenic rupture. It is important to include splenic rupture as a differential diagnosis for acute abdominal pain, especially in patients with hematologic malignancy, since early recognition and treatment increase patient survival and improve the prognosis.

Conclusion

Even if spontaneous splenic rupture is rare, every clinician should have in mind the reflex to think of it, especially in patients with hematologic malignancies.

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The objective of this study is to highlight the seriousness of this condition and the different diagnostic and therapeutic modalities.

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Spontaneous rupture of the spleen (SPR) is a rare and severe affection, difficult to diagnose.

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The prognosis is depending on the quality of care and the nature of the etiology.

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Splenectomy remains the cornerstone of the treatment of splenic rupture.

Spontaneous splenic rupture: a rare first presentation of diffuse large B cell lymphoma

Spontaneous splenic rupture (SSR) is a rare but potentially life-threatening entity. It can be due to neoplastic, infectious, haematological, inflammatory and metabolic causes. An iatrogenic or an idiopathic aetiology should also be considered. Depending on the degree of splenic injury and the haemodynamic status of the patient, it can be managed conservatively. A 61-year-old man presented to the emergency department with an acute abdomen, hypovolaemic shock and clotting abnormalities. However, his focused assessment with sonography for trauma showed no evidence of an aortic aneurysm, rupture or dissection. Further investigation with a CT angiogram aorta confirmed a subcapsular splenic haematoma with free fluid in the pelvis and a mass in the superior pole of the spleen. He was diagnosed with an SSR. He was initially managed non-operatively. However, his repeat CT showed an enlarging haematoma and he underwent embolisation of his splenic artery. Ultrasound-guided core biopsy of his splenic mass confirmed the diagnosis of diffuse large B-cell lymphoma. This paper will discuss the clinical presentation, differential diagnosis and management of SSR. Furthermore, it provides an important clinical lesson to maintain a high index of clinical suspicion for splenic injury in patients presenting with left upper quadrant abdominal pain radiating to the shoulder. This case also reinforces the importance of close observation and monitoring of those individuals treated conservatively for signs of clinical deterioration.

Teenage kicks: splenic rupture secondary following infectious mononucleosis

A 16-year-old man was brought to the emergency department by his father with apparent alcohol intoxication. While in the department, it was noted that the patient had ongoing tachycardia, hypotension and abdominal pain. His recent medical history included a self-resolving illness of fatigue, muscle aches and sore throat. A CT scan of his abdomen revealed an enlarged spleen with a splenic infarct and rupture, likely secondary to infectious mononucleosis. The patient was treated conservatively for 12 days.

Splenic rupture after elective cardioversion

Splenic laceration and rupture are common phenomena among patients in a traumatic setting, especially in blunt trauma. Much more unusual, however, is splenic injury without a known insult. Several case reports and studies have been written about spontaneous splenic injury in patients with viral, haematological or malignant processes. Recently, we encountered a patient with a spontaneous splenic rupture and no preceding trauma apart from semielective cardioversion. Operative decision-making was complicated by the fact that he required systemic anticoagulation for atrial fibrillation. He eventually underwent splenectomy and made an uneventful recovery.

Atypical manifestations of Epstein-Barr virus in children: a diagnostic challenge

OBJECTIVE

Clarify the frequency and the pathophysiological mechanisms of the rare manifestations of Epstein-Barr virus infection.

SOURCES

Original research studies published in English between 1985 and 2015 were selected through a computer-assisted literature search (PubMed and Scopus). Computer searches used combinations of key words relating to "EBV infections" and "atypical manifestation."

SUMMARY OF THE FINDINGS

Epstein-Barr virus is a herpes virus responsible for a lifelong latent infection in almost every adult. The primary infection concerns mostly children and presents with the clinical syndrome of infectious mononucleosis. However, Epstein-Barr virus infection may exhibit numerous rare, atypical and threatening manifestations. It may cause secondary infections and various complications of the respiratory, cardiovascular, genitourinary, gastrointestinal, and nervous systems. Epstein-Barr virus also plays a significant role in pathogenesis of autoimmune diseases, allergies, and neoplasms, with Burkitt lymphoma as the main representative of the latter. The mechanisms of these manifestations are still unresolved. Therefore, the main suggestions are direct viral invasion and chronic immune response due to the reactivation of the latent state of the virus, or even various DNA mutations.

CONCLUSIONS

Physicians should be cautious about uncommon presentations of the viral infection and consider EBV as a causative agent when they encounter similar clinical pictures.

Splenic rupture in infectious mononucleosis: A systematic review of published case reports

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.

Spontaneous rupture of the spleen in a patient with systemic lupus erythematosus initially presented as Evans syndrome

BACKGROUND

Although splenic abnormalities are common in patients with lupus, spontaneous rupture of spleen is extremely rare.

OBSERVATIONS

A 15-year-old boy with new-onset Evans syndrome subsequently diagnosed as systemic lupus erythematosus developed spontaneous rupture of spleen during the course of his illness. Despite the severe thrombocytopenia, he was managed conservatively with gradual regression of hematoma without further complication.

CONCLUSIONS

Splenic rupture may occur spontaneously in the course of systemic lupus erythematosus. We conclude that conservative treatment of splenic rupture may be preferred especially in immunocompromised patients to avoid surgical complications.

Spontaneous rupture of the spleen operated in gynecological unit mistaken for ruptured hemorrhagic ovarian cyst: total splenectomy

Spontaneous splenic rupture is always neglected when consulting acute abdominal pains in gynecological emergencies. It constitutes about 1% of all splenic ruptures and can be managed by abstention, surgery or embolization. We present the case of a young lady who was diagnosed of spontaneous rupture during surgery that was mistaken for ruptured hemorrhagic ovarian cyst and finally treated by total splenectomy. The pre-operative work up was absolute for a rupturred hemorrhagic cyst and secondariy for a ruptured ectopic gestation.

Spontaneous splenic rupture in infectious mononucleosis: case report and review of the literature

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.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

BACKGROUND

Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion.

METHODS

Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.

RESULTS

We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy.

CONCLUSIONS

Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

Hemorrhagic shock as a sequela of splenic rupture in a patient with infectious mononucleosis: focus on the potential role of salicylates

Despite the fact that the vast majority of splenic ruptures are traumatic, infectious mononucleosis has been incriminated as a major predisposing factor that affects the integrity of the spleen, thus causing atraumatic ruptures and life-threatening hemorrhages. Herein we present a case of a 23-year-old Caucasian male who underwent an emergency laparotomy for acute abdomen and hemorrhagic shock, caused by spontaneous splenic rupture secondary to infectious mononucleosis. The potential role of salicylates in the development of a hemorrhagic complication in a patient with infectious mononucleosis is discussed.

Acute abdomen due to spontaneous splenic rupture as the first presentation of lung malignancy: a case report

Introduction

Spontaneous splenic rupture is well recognized in the context of hematological malignancies (lymphoproliferative and myeloproliferative disorders); a few case reports have also linked solid tumors, such as pancreatic and liver cancer, with the occurrence of spontaneous splenic rupture. This is the first case report of lung cancer as a likely cause of spontaneous splenic rupture.

Case presentation

A 61-year-old Caucasian woman presented to our hospital with non-specific symptoms. She developed an 'acute' abdomen and went into a state of shock within twelve hours of her presentation. She was diagnosed with spontaneous splenic rupture with radiology and following a laparotomy. She made an uneventful recovery postoperatively and was simultaneously found to have a bronchial adenocarcinoma.

Conclusion

Spontaneous splenic rupture is a potentially fatal but often unrecognized cause of acute abdomen. It should be routinely considered in the differential diagnosis of acute ('surgical') abdomen and when present it should be promptly dealt with, most commonly with a laparotomy. Once the diagnosis is confirmed there should be an aggressive drive to identify an underlying etiology; malignancy is the commonest culprit. Solid tumors should be considered as underlying causes despite being less common than hematological neoplasms. This case report demonstrates lung malignancy as an underlying precipitating cause of spontaneous splenic rupture.

Spontaneous splenic rupture precipitated by cough: a case report and a review of the literature

Spontaneous rupture of a normal spleen without a history of trauma is a rare clinical entity. We report on a case of atraumatic splenic rupture in a 61-year-old man who presented to the emergency department for abdominal pain and hypotension. There was no evidence of hematologic or infectious disease involving the spleen. The chronic cough described by the patient was the main trigger for the rupture. Although, spontaneous splenic rupture is rare, it is vital that physicians consider this diagnosis when evaluating patients with abdominal pain and hypotension. Failure to consider splenic rupture could be catastrophic and early diagnosis is essential for a better outcome.

Pharyngitis of infectious mononucleosis: computed tomography findings

Two women presented with sore throat and fever. Their symptoms were not alleviated by antibiotics. Cervical computed tomography (CT) with contrast enhancement demonstrated enlargement of predominant posterior cervical lymph nodes and streaky heterogeneous tonsils with interspersed low attenuation. They were diagnosed as having infectious mononucleosis by their laboratory data. Thus, when radiologists encounter these CT findings of pharyngitis that is not alleviated by antibiotic therapy, infectious mononucleosis should be considered in the differential diagnosis.