Spontaneous splenic rupture in infectious mononucleosis.

Abstract

Abdominal complaints in patients with infectious mononucleosis should alert the surgeon to the potential, and possibly fatal, risk of splenic rupture. Radiologic evaluation by ultrasonography and computed tomography is indicated for appropriate management. We describe a case in which a diagnosis of splenic rupture occurring spontaneously on a background of infectious mononucleosis was made as a result of a high index of suspicion. The patient was treated conservatively.

Introduction

Spontaneous splenic rupture occurs in 0.1 to 0.5% of patients with infectious mononucleosis, making it the most common potentially fatal complication of this infection. (1,2) In this article, we describe a case that illustrates the importance of radiologic investigation for patients with infectious mononucleosis and abdominal complaints. This case also highlights the role of a nonsurgical approach to treating patients at risk of spontaneous splenic rupture.

Case report

A 15-year-old boy was admitted with a 7-day history of severe tonsillitis secondary to infectious mononucleosis. On admission, he was pyrexial and exhibited associated cervical lymphadenopathy. No palpable organomegaly was observed, and there was minimal tenderness in the left upper quadrant of the abdomen. The patient had no history of recent abdominal trauma or sports injury. He had absolute lymphocytosis (lymphocyte count: 12.24 x [10.sup.9]/L), a positive Monospot test, and an elevated liver enzyme level.

The tonsillitis responded to broad-spectrum antibiotics, but on hospital day 4, the patient developed a more constant left upper quadrant pain and associated diarrhea. Ultrasonography of the abdomen detected evidence of splenic enlargement and a small amount of intraperitoneal fluid (figure, A). Computed tomography (CT) of the abdomen revealed the presence of a subcapsular splenic hematoma and free blood in the abdomen (figure, B). The patient's blood pressure remained stable throughout, he was mildly tachycardic, and his hemoglobin level had fallen to 5.2 g/dl. A general surgical consult was obtained, and conservative management was advocated. A blood transfusion was deemed to be unnecessary.

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The patient remained stable throughout his inpatient stay, and his abdominal symptoms soon resolved; he was discharged 8 days postadmission. Follow-up at the ENT and the general surgical outpatient clinics was arranged. Repeat ultrasonography follow-up at 3 months showed that the capsular hematoma had resolved and the size of the spleen had returned to normal. At the 6-month follow-up, the splenic size remained normal.

Discussion

Tonsillitis associated with infectious mononucleosis is a common condition that requires hospital admission. Dommerby et al reported that abdominal ultrasonography demonstrated a 51 to 59% increase in splenic size in almost all patients with infectious mononucleosis, but only 17% of these spleens were clinically palpable? These authors also reported that ultrasonic assessment detected associated hepatomegaly in 50% of cases.

The increase in splenic volume occurs secondary to mononuclear cell infiltration of the parenchyma. (4) Capsular and trabecular changes that progress to rupture occur over a period of 14 to 28 days. (5) The risk of splenic rupture is highest during the second and third weeks of illness, when the volume increase in splenic size is at its peak; rupture 4 weeks after infection is uncommon. (1,6) Liver enzymes are elevated during this period, and they return to normal by the fifth week; a correlation has been noted between splenic size and lactate dehydrogenase levels. (3,4) However, because there is no correlation between the derangement of liver enzymes and the incidence of splenic rupture, the risk of rupture is difficult to determine. (3)

Abdominal pain is rare in the presence of splenomegaly, so its onset should alert the clinician to the possibility of splenic rupture, as it did in our case. (1,2,5,6) The pain is typically epigastric or located in the left or right hypochondrium; referral to the left shoulder (Kehr's sign), right shoulder, or scapula can occur as a result of diaphragmatic irritation by free intraperitoneal blood. (1,5,6) Referral of pain is seen in 50% of patients with ruptured spleens. (5,6)

Immediate management following appropriate resuscitative measures should involve urgent ultrasonography, followed by CT of the abdomen if indicated, as occurred in our case. General surgical advice should be obtained as soon as possible. The traditional treatment for these patients has been splenectomy, but more recently, there has been a trend toward conservative management for patients who remain hemodynamically stable. (7,8) While the presence of abdominal findings in a patient admitted with infectious mononucleosis should be considered an indication for radiologic investigation, routine ultrasonography for all patients admitted with infectious mononucleosis is not necessary because in most cases the findings will not alter subsequent management.

Patients who are treated conservatively should be cautioned against returning to contact sports for at least 1 month after admission to reduce the risk of rupture. Although 3 to 6 months of abstinence from contact sports has been advocated for active athletes, there is no evidence to sustain a period longer than 1 month. (4,5,9) For active athletes, serial ultrasonography for the first month after admission is recommended to confirm resolution of splenomegaly. (l,4,5) Avoidance of alcohol during the first month after admission is also advised. (9)

References

(1.) Chapman AL, Watkin R, Ellis CJ. Abdominal pain in acute infectious mononucleosis. BMJ 2002;324:660-1.

(2.) Vitello J. Spontaneous rupture of the spleen in infectious mononucleosis: A failed attempt at nonoperative therapy. J Pediatr Surg 1988;23:1043-4.

(3.) Dommerby H, Stangerup SE, Stangerup M, Hancke S. Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning. J Laryngol Otol 1986; 100:573-9.

(4.) Papesch M, Watkins R. Epstein-Barr virus infectious mononucleosis. Clin Otolaryngol Allied Sci 2001;26:3-8.

(5.) Rutkow IM. Rupture of the spleen in infectious mononucleosis: A critical review. Arch Surg 1978;113:718-20.

(6.) Safran D, Bloom GP. Spontaneous splenic rupture following infectious mononucleosis. Am Surg 1990;56:601-5.

(7.) Schuler JG, Filtzer H. Spontaneous splenic rupture. The role of nonoperative management. Arch Surg 1995;130:662-5.

(8.) Guth AA, Pachter HL, Jacobowitz GR. Rupture of the pathologic spleen: Is there a role for nonoperative therapy? J Trauma 1996;41:214-18.

(9.) Haines JD Jr. When to resume sports after infectious mononucleosis. How soon is safe? Postgrad Med 1987;81(1):331-3.

Seng Guan Khoo, AFRCSI; Ihsan Ullah, FRCSI; Kevin P. Manning, FRCS; John E. Fenton, FRCS (ORL-HNS)

From the Department of Otolaryngology--Head and Neck Surgery, Mid-Western Regional Hospital and the National Institute of Health Sciences, Limerick, Ireland.

Reprint requests: Mr. Seng G. Khoo, 62 Hybreasal House, Kilmainham, Dublin 8, Ireland. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The information in this article was originally presented at a meeting of the Munster Otolaryngology Society; Nov. 21, 2001; Limerick, Ireland.