A large splenic cyst: "incindentalocyst".

To the Editor: Splenic cysts are rare, and many are asymptomatic and are found incidentally. We report an interesting case of a young diabetic with ketoacidosis who was found to have an incidental large splenic cyst mimicking the clinical picture of diabetic gastroparesis.

A 31-year-old white male with type 1 diabetes mellitus presented with nausea, vomiting, diarrhea and upper abdominal pain of 5 days' duration. His past medical history was significant for multiple hospitalizations for diabetic ketoacidosis secondary to medical noncompliance. In addition, 2 months before admission he was involved in a motor vehicle collision. He had denied symptoms of persistent nausea or vomiting before this admission. On physical examination, he was found to be lethargic with a BP of 100/82 mm Hg and a pulse rate of 108/m. The patient was tachypneic with a respiratory rate of 24/min and was afebrile. Abdominal examination was unremarkable except for tenderness in the epigastrium and both hypochondrial regions. Stool examination was heme negative.

Laboratory data revealed a hemoglobin of 13.2 g/dL, WBC 15 K/[mm.sup.3], platelets 197 K/[mm.sup.3], MCV 92.6 fl., blood glucose 439 mg/dL, BUN 28 mg/dL, serum creatinine 1.9 mg/dL, serum [Na.sup.+] 135 mmol/L, [K.sup.+] 4.5 mmol/L, [Cl.sup.-] 101 mmol/L, and C[O.sub.2] 10 mmol/L. Serum amylase 75 U/L, serum lipase 227 U/L. Blood and urine cultures were sterile. Urinalysis revealed ketones 4+, glucose 3+ without any cells or casts. Arterial blood gas: pH 7.31, pC[O.sub.2] 27 mm Hg, pa[O.sub.2] 120 mm Hg, HC[O.sub.3] 12 mMol/L, Sa[O.sub.2] 99% on 1.5 L [O.sub.2] supplementation.

The patient was admitted to the MICU for further management of his diabetic ketoacidosis (DKA), which was treated with IV fluids and insulin supplementation, which resulted in a complete biochemical resolution over the next 36 hours. However, he continued to have persistent abdominal pain, nausea and vomiting. Abdominal ultrasound did not show any evidence of hepatobiliary disease but revealed a multiseptate cystic mass within the spleen. CT scan of abdomen confirmed a multiseptate splenic mass, measuring 12 X 8 cm and compressing the gastric fundus (Fig. 1). Upper gastrointestinal endoscopy was unremarkable except for mild esophagitis. (Fig. 2)

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Given his clinical condition, pressure symptoms and multilocularity of the cystic structure, a splenic abscess was considered. The patient underwent splenectomy. Pathology revealed an enlarged spleen measuring 15.5 X 13.2 X 8 cm and weighing 490 g with more than two-thirds of the spleen occupied by cysts. Microscopic examination revealed no identifiable lining cells with cysts comprised mainly of organizing fibrin and blood clots. Postoperatively, the patient did well and has remained symptom free.

In the present case, the compressive symptoms of abdominal pain, nausea and persistent vomiting mimicked those of diabetic gastroparesis. A recent motor vehicle collision in addition to his symptoms prompted imaging of his abdomen. The possibility of a splenic abscess precipitating ketoacidosis was considered, but the patient had been afebrile and his blood cultures were sterile. In view of the cyst size, multiloculation and compression of the stomach, a splenectomy was done. The histopathology confirmed the diagnosis of a hemorrhagic pseudocyst.

Splenic cysts are rare entities. Cysts are classified as primary or secondary depending on the presence or absence of a cellular lining. Primary cysts are congenital or parasitic (echinococcal). Secondary splenic cysts include posttraumatic (hemorrhagic or serosal), inflammatory and degenerative. Posttraumatic cysts are formed either as a result of encapsulation of a hematoma or invagination of splenic surface mesothelium into splenic parenchyma following trauma. (1,2) The majority of splenic cysts are silent and are found incidentally on imaging. (3) Symptoms produced may be secondary to the size of the cyst or occur following compression of surrounding structures. Complications of splenic cysts include infection, hemorrhage, and rupture into the peritoneal cavity and in case of hydatid cysts, fistulization to the colon. Histology helps determine whether the cysts are primary or secondary.

Treatment of splenic cysts has changed over the years to a more conservative approach. However, the presence of certain indications such as large multiloculated cysts, large cysts involving the hilum, those causing compressive symptoms and hydatid splenic cysts demand splenectomy. Small (< 4 cm), asymptomatic posttraumatic pseudocysts may be simply observed, as they usually involute with time.

Adrian Sequeira, MD

Louisiana State University Health Sciences Center

Shreveport, LA

Naveen K. Atray, MD, FASN

Louisiana State University Health Sciences Center and Overton Brooks VA Medical Center

Shreveport, LA

Tushar J. Vachharajani, MD, FASN

Louisiana State University Health Sciences Center and Overton Brooks VA Medical Center

Shreveport, LA

References

1. Cinzia L, Konstantinos NH, Adil RE, et al. Posttraumatic cyst of the spleen: A case report and review of literature. IntSurg 2002;87:152-157.

2. Klepac S, Samett EJ. Splenic, Trauma. 21 October 2002. Available at: http://www.emedicine.com/radio/topic645.htm. Accessed September 22, 2005.

3. Desai MB, Kamdar MS, Bapat RR, et al. Splenic cysts: (report of 2 cases and review of literature). J Postgrad Med 1981;27:251-252.