Spontaneous splenic rupture in a patient with infectious mononucleosis.

We present a case of spontaneous, atraumatic splenic rupture secondary to Epstein-Barr virus (EBV) infection, in a young, female patient. Splenic rupture is a rare complication of EBV infection, but is associated with the highest mortality. Additionally, this case illustrates the diagnostic challenge in a patient presenting in atypical manner, with only left-sided pleuritic chest pain, and lacking any of the classical tonsillitis symptoms associated with EBV infection.

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.

Varicella zoster virus infection is an unusual cause of splenic rupture.

A 22-year-old man presented with a 1-day history of severe abdominal pain. He developed a generalised vesicular rash 12 h prior to admission. On examination, he was maximally tender with peritonism in the lower abdomen. Working diagnosis was perforated appendix and a decision to investigate with CT was made, which showed intra-abdominal haemorrhage likely arising from a ruptured spleen. After a period of observation, he subsequently underwent laparotomy and emergency splenectomy. Viral PCR from vesicular fluid was positive for varicella zoster virus. Viral serology was otherwise negative.

Successful emergency splenectomy during cardiac arrest due to cytomegalovirus-induced atraumatic splenic rupture.

A 27-year-old woman was admitted to the emergency department with fever and a petechial rash on suspicion of meningitis. Shortly after arriving she developed cardiac arrest. Blood work up showed severe lactate acidosis, anaemia and thrombocytopenia. A focused assessment with sonography in trauma scan showed free intraperitoneal fluid and an emergency laparotomy revealed massive bleeding from a ruptured spleen. The patient was successfully resuscitated. She proved to be infected with cytomegalovirus causing idiopathic thrombocytopenic purpura, splenomegaly and splenic rupture. She was treated for 14 days with ganciclovir and meropenem and discharged on recovery. Atraumatic splenic rupture caused by viral infection is a rare condition although well described. In the case of our patient, thrombocytopenia added to the severity of the splenic rupture. A multidisciplinary team approach was essential for the management and the eventual recovery of the patient.

Splenic rupture associated with primary CMV infection, AMSAN, and IVIG.

Splenic rupture is a rare complication of primary cytomegalovirus infection, but has not been reported after administration of intravenous immunoglobulin or in the setting of the Guillain-Barré syndrome and its many variants, which often lead to treatment with intravenous immunoglobulin. There is strong evidence that intravenous immunoglobulin causes sequestration of erythrocytes in the spleen and extravascular hemolytic anemia. This may result in a two-hit scenario that clinicians should be aware of, where a patient who is at risk for splenic rupture due to primary cytomegalovirus infection receives intravenous immunoglobulin as treatment for the cytomegalovirus-associated Guillain-Barré syndrome, further increasing their risk of rupture.

Chest pain in a young patient: an unusual complication of Epstein-Barr virus.

A 29-year-old man presented with sudden left-sided pleuritic chest pain on a background of sore throat during the preceding week. On examination he had tender cervical lymphadenopathy, he was tachycardic and had a 24 mm Hg blood pressure difference between the left and right arms. Bloods revealed deranged liver function tests and a lymphocytosis. His D-dimer was raised, hence he was treated for presumed pulmonary embolism before imaging was available. Monospot test was positive. He subsequently had both a CT pulmonary angiogram and a CT angiogram of the aorta to exclude pulmonary embolism and aortic dissection. The CT revealed splenomegaly with a large subdiaphragmatic haematoma secondary to splenic rupture. This had likely caused referred pain through diaphragmatic irritation. He was taken to theatre for urgent splenectomy. The unifying diagnosis was infectious mononucleosis complicated by spontaneous splenic rupture secondary to Epstein-Barr virus infection.

Spontaneous splenic rupture and multiple lung embolisms due to cytomegalovirus infection: a case report and review of the literature.

A 53-year-old woman presented with a spontaneous splenic rupture. The splenic rupture was considered a complication of a primary cytomegalovirus (CMV) infection as were multiple pulmonary embolisms. CMV infections are common but are most often asymptomatic, and to our knowledge only 15 cases complicated with splenic rupture have been published.

[Spontaneous rupture of the spleen after infectious mononucleosis]. / Spontan miltruptur efter infektiøs mononukleose.

Non-traumatic rupture of the spleen (NRS) is a rare but serious complication to infectious mononucleosis (IM) and it is important to have in mind, when patients have IM. Although splenectomy has been advocated as the appropriate treatment for this problem, the trend goes towards conservative treatment of the haemodynamically stable patients, but because of its rarity no clear guidelines have been suggested. We present a case of a 18-year-old boy with IM who had NRS with subcapsular haematoma and was treated conservatively. He recovered completely.

[Occult rupture of the spleen in a patient with infectious mononucleosis]. / Rottura splenica "occulta" in paziente con mononucleosi infettiva.

INTRODUCTION: Rupture of the spleen can be secondary to abdominal traumas (usually closed trauma) or spontaneous, can interest an organ normal or with morphological alterations secondary to various pathologies. Among the diseases responsible of occult rupture, infectious diseases are the most frequent and, among these, infectious mononucleosis, that is complicated with splenic rupture in 0.5% of the cases, with 30% of mortality. CASE REPORT: P.M., 16 years old female, admitted with acute abdomen, progressive anaemia and incipient cardiovascular instability, associated with suggestive clinical diagnosis of infectious mononucleosis, confirmed by serological findings and histological examination. Because of the imaging of subcapsular splenic haematoma, probably ruptured and with peritoneal bleeding we opt for emergency laparotomy intraoperative findings allows to splenectomy. DISCUSSION: Splenic rupture in infectious mononucleosis often presents as left hypochondrial pain, rare in uncomplicated cases; its occurrence in a patient with a recent diagnosis of infectious mononucleosis or with clinical or laboratory features suggestive of acute EBV infection, should always be investigated with an urgent abdominal ultrasound scan or CT. This approach is mandatory when hypochondrial pain is associated with pain referred to the left shoulder (Kehr's sign), peritoneal irritation and haemodynamic instability. Patients with splenic rupture in infectious mononucleosis generally undergo emergency splenectomy.

Infective splenic rupture presenting with symptoms of a pulmonary embolism.

Splenic rupture following infectious mononucleosis is rare. The case history is presented of a man who presented with sudden onset pleuritic left chest pain. An ultrasound scan of the abdomen showed an enlarged spleen with an abnormal echo pattern and a CT scan of the abdomen showed severe splenic rupture. The patient remembered that he had been unwell 2 weeks earlier with flu-like symptoms and enlarged cervical lymph nodes. Serological examination was positive for Ebstein-Barr virus, confirming the diagnosis of splenic rupture following splenomegaly due to infectious mononucleosis. Management was initially conservative but he became haemodynamically unstable and an emergency splenectomy was performed.

A fatal case of spontaneous rupture of the spleen due to dengue virus infection: case report and review.

Dengue hemorrhagic fever (DHF) is being seen more frequently in adults as a consequence of shifting patterns of infection and immunity and there has been an apparent increase in the complications of dengue infection. Spontaneous splenic ruptures are rare but life-threatening complications of infectious diseases. We describe a fatal case of spontaneous splenic rupture in an adult patient with DHF. A case of spleen rupture may be misdiagnosed as shock syndrome. Physicians should be aware of the possibility of splenic rupture in areas where dengue infection is endemic. Early diagnosis and treatment of splenic rupture should improve clinical outcomes.

[Spontaneous splenic rupture as a complication of symptom-free infections mononucleosis]. / Tünetmentes mononucleosis infectiosa szövodményeként kialakult spontán lépruptura.

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.

[Spontaneous splenic rupture in the course of infectious mononucleosis]. / Samoistne pekniecie sledziony w przebiegu mononukleozy zakaznej.

Spontaneous splenic rupture (SSR) in the course of infectious mononucleosis (IM) is a rare but potentially fatal complication. Mortality rate is relatively high, therefore emergency splenectomy is a life-saving intervention. In case of undergoing urgent operation there is no possibility to initiate proper prophylaxis of overwhelming infection. The humoral and cellular immunologic response impairment is a reason for life-threatening complications of splenectomised person. Asplenic children should receive infection prophylaxis immediately post splenectomy. We report two cases of splenic rupture inpatients with IM. The prevention of infection was initiated in both children. The mainstays of prophylaxis are: immunization, chemoprophylaxis and education. Complex information concerning asplenia-related subjects should be provided for patients and their parents.

[Spontaneous splenic rupture in a patient with cytomegalovirus infection]. / Rottura spontanea di milza in presenza di infezione citomegalica. Descrizione di un caso clinico.

The Authors report a case of spontaneous splenic rupture in a patient with Cytomegalovirus infection, stress the main characteristics of this infection and describe the mechanism that, during the viral infection, causes morphological and functional alterations of the spleen. The hypersplenism secondary to hyperfunctioning, the formation of immunocomplexes with secondary infarction, mainly of the white pulp, and the disseminated intravascular coagulation are responsible, as in the observed case, of the rupture of splenic capsula. The Authors conclude that the wide diffusion of Cytomegalovirus infection needs the knowledge of all the pathologic signs of this infection to make a timely diagnosis and treatment.

[Spontaneous spleen rupture associated to active cytomegalovirus infection]. / Ruptura espontánea de bazo asociada a infección activa por citomegalovirus.

We present a 24 year old immunocompetent male who developed a spontaneous rupture of the spleen (SRE) during an acute cytomegalovirus (CMV) infection. The only previous clinical feature was the presence of flu-like symptoms two weeks before the SRE. The diagnosis was confirmed by the presence of IgM antibodies to CMV in the serum and a positive CMV-PCR in the splenic biopsy after splenectomy. The patient recovered completely after surgery. Spontaneous splenic rupture is an uncommon event associated with primary cytomegalovirus infection, and this is the first case reported in our country.