Splenic cyst presenting as severe hydronephrosis in a pediatric patient

Large cystic abdominal masses can represent a diagnostic dilemma despite advanced diagnostic and imaging techniques. We report a case of a large cystic mass initially managed as a giant ureteropelvic junction obstruction, but ultimately found to be a congenital splenic cyst. Focus is placed on the diagnostic evaluation of large cystic abdominal masses.     

Splenic embolization for splenic laceration in a patient with mononucleosis

Splenomegaly is a sequela of infectious mononucleosis. The potential for traumatic rupture of an enlarged spleen is well recognized. Recently, splenic artery embolization has gained popularity for the treatment of splenic injury. However, embolization has not been described for splenic injury in an enlarged spleen secondary to mononucleosis. We report the case of a 15-year-old girl who was the restrained passenger in a motor vehicle crash. On examination at an American College of Surgeons-verified Level 1 trauma center, the patient was found to have abdominal pain. A focused assessment with sonography for trauma examination revealed fluid in Morison's pouch. A subsequent spiral CT scan with intravenous contrast revealed a markedly enlarged spleen with a shattered upper pole. The patient denied symptoms of mononucleosis; however, a spot mononucleosis test was positive. The patient was admitted to the pediatric intensive care unit for observation. She remained hemodynamically stable, but her initial hemoglobin of 9.2 g/dL fell to 7.1 g/dL 6 hours later. Splenic artery embolization was performed and the upper pole of the spleen was selectively embolized. The hemoglobin remained stable and the patient was transferred to the pediatric ward. On postembolization day five, the patient was dismissed with a hemoglobin of 9.7 g/dL. This case demonstrates that splenic embolization is a viable alternative to operative treatment even in the presence of splenomegaly secondary to mononucleosis.     

Intracavitary administration of amphotericin B in the treatment of cerebral aspergillosis in a non immune-compromised patient: case report and review of the literature

A 24-year-old man presented with cerebral aspergillus fungal granuloma involving the left frontal region secondary to pulmonary aspergillosis. He was otherwise healthy with no evidence of immune-suppression. Because of poor penetration of amphotericin B into the brain and cerebrospinal fluid (CSF), this patient was treated by a combination of systemic and local therapy in addition to surgical excision resulting in a cure with follow up for more than three years. This form of treatment produced no untoward long-term side effects or neurological sequel. On review of the literature on aspergillosis of the central nervous system (CNS), we found that six patients, including the present case, have been reported who survived longer than 1 year; their treatment included local administration of antifungal agent in the abscess cavity or into cerebral ventricles in order to control this devastating, treatment-resistant pathological fungal infection.     

Splenic rupture and haemoperitoneum in a patient with non-compaction of the left ventricular myocardium

The anaesthetic and critical care management of blunt abdominaltrauma in a patient previously diagnosed with non-compactionof the left ventricular myocardium (a rare autosomal dominantinherited disease) is reported. The management was influencedby the presence of an implanted automated internal defibrillatorand treatment with anticoagulants because of the high frequencyof severe arrhythmias and systemic embolism. The pathophysiologyof ventricular non-compaction is reviewed briefly.     

Splenic malformation in a patient with Klippel-Trenaunay syndrome: a case report

A 22-year-old woman with a diagnosis of Klippel-Trenaunay syndrome presented with pain in the left hypochondrium and vomiting. Investigations revealed a huge splenomegaly with multiple hypodense lesions and irregular, linearly enhanced areas. She underwent splenectomy and had good postoperative recovery. Histopathology showed hemangioma/lymphangioma of the spleen.     

Splenic preservation in children

The diagnosis of splenic injury can be made with almost 100% certainty by physical examination and nuclear imaging or computerized axial tomography, eliminating the need for surgical exploration in children who are stable and have no evidence of an associated intra-abdominal injury. The nonoperative approach of treatment has been successful in over 95% of selected cases. Operative splenic preservation methods, including splenorrhaphy with or without splenic artery ligation, hemisplenectomy, and splenectomy with autotransplantation have been attempted and each has a role in the unstable patient requiring operation. Splenectomy alone carries a 1.5% risk of overwhelming postsplenectomy infection which is only partially prevented by Pneumovax^® and antibiotics. The regionalization of trauma care in children ensures proper monitoring of the injured child, and a surgeon knowledgeable about the treatment options has made splenic preservation a reality

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Resumen El diagnóstico de lesión esplénica puede ser hecho con casi 100% de certeza por medio del examen físico y la imagenología nuclear o la tomografía axial computadorizada, con lo cual se elimina la necesidad de exploratión quirúrgica en niños que se hallen estables y sin evidencia de lesión intraabdominal asociada. El enfoque de tratamiento no operatorio ha sido exitoso en el 95% de casos seleccionados. Los métodos de conservatión operatoria del bazo, incluyendo la esplenorrafia con o sin ligadura de la arteria esplénica, la hemiesplenectomía y la esplenectomía con autotransplante han sido intentados y cada uno posee una indicación en el paciente inestable que requiere opération. La esplenectomía conlleva un riesgo de 1.5% del desarrollo de infección devastadora postesplenectomía, la cual sólo puede ser parcialmente prevenida con Pneumovax^® y antibióticos. La regionalización de la atención del trauma en niños asegura una monitoría adecuada del niño traumatizado, y el cirujano, conocedor de las diferentes opciones terapéuticas, ha hecho de la preservatión esplénica una realidad.

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Résumé Le diagnostic de lésion traumatique de la rate peut être porté avec certitude dans près de 100% des cas par l'examen clinique, la scintigraphie et la tomodensitométrie évitant ainsi de pratiquer une laparotomie exploratrice chez les enfants dont l'état général reste stable et qui ne présentent pas de signes d'une lésion intra-abdominale associée. Cette attitude a été marquée par plus de 95% de succès dans les cas sélectionnés. Chez le sujet dont l'état général n'est pas stable une attitude conservatrice a été adoptée: splénorraphie avec ou sans ligature de l'artère splénique, hémi-splénectomie ou splénectomie avec autotransplantation. La splénectomie comporte un risque d'infection dont le taux atteint 1.5%, risque qui est prévenu en partie par la vaccination (Pneumovax^®) et par l'antibiothérapie. La conservation de la rate traumatique est devenue une réalité depuis que le traitement est assuré chez l'enfant dans les hôpitaux d'enfants par des chirurgiens se consacrant à la chirurgie infantile.

     

Splenic infarction: an unrecognized cause of culture-negative peritonitis in a continuous ambulatory peritoneal dialysis patient

The appearance of cloudy peritoneal dialysis effluent in combination with the clinical manifestations of peritonitis usually heralds infectious peritonitis and the diagnosis is established with routine cultures. However, patients may present with culture-negative cloudy dialysate effluent and after ruling out atypical infectious etiologies, other intraabdominal causes should be considered in the differential diagnosis. A 57-year-old male with uremia on continuous ambulatory peritoneal dialysis with a pertinent history of restrictive cardiomyopathy and chronic atrial fibrillation suffered from abdominal pain and persistent culture-negative cloudy peritoneal dialysate. Clinical improvement was limited after empiric antibiotic treatment and all bacteriologic workups were negative. Isolated spleen infarction, a rare cause of culture-negative peritonitis, was disclosed by abdominal computed tomography. Spleen infarction is still an unrecognized cause of culture-negative peritonitis and is frequently overlooked. A high degree of suspicion is needed in CAPD patients with thromboembolism risk who present with unexplained persistent abdominal pain and cloudy PD effluent.