Spontaneous splenic rupture due to infectious acute mononucleosis: case report

Infectious mononucleosis is an acute, viral, illness associated with a high incidence of splenomegaly. Spontaneous splenic rupture is a rare but life-threatening complication of infectious mononucleosis. The authors report the case of a 19-year-old patient with an infectious mononucleosis causing a spontaneous splenic rupture. When rupture occurs the mortality has been significant. The spleen may be vulnerable for the histopathologic changes that occur as a result of this illness. Two thirds of patients with infectious mononucleosis develop an enlarged spleen, but in only 0.5% of all patients will it rupture. Abdominal pain and tachycardia are unusual in uncomplicated infectious mononucleosis and should alert a doctor to the possibility of spontaneous splenic rupture. The diagnosis of splenic rupture may be confirmed in a variety of ways. In this patient ultrasound and Rutkow's criteria may aid in establishing the diagnosis. In patients with infectious mononucleosis suspected of having rupture of the spleen, a rapid but thorough assessment and prompt implementation of appropriate management should minimize the associated morbidity and mortality. On the basis of review of the medical literature and of our own experience, we advocate emergent splenectomy for spontaneous splenic rupture in patients with infectious mononucleosis.     

Surgical implications of infectious mononucleosis

A series of 50 consecutive patients admitted to the hospital with a primary diagnosis of infectious mononucleosis is reviewed, with particular emphasis on the abdominal complaints and physical findings. Forty-eight percent of the patients had abdominal pain. Abdominal symptoms were the chief complaint in 24 percent of the patients. Two cases of splenic rupture are presented. One case of spontaneous rupture of the spleen is emphasized, as there are only 18 well-documented cases of true spontaneous rupture of the spleen in infectious mononucleosis. Four young persons with infectious mononucleosis in Portland, Oregon, recently bled to death at home from a ruptured spleen. Guidelines are presented to aid the surgeon in evaluating the patient with infectious mononucleosis. The risk of splenic rupture persists after the patient recovers. Recommendations are made regarding the resumption of physical activity in these young, active patients.     

Spontaneous rupture of the spleen: Two case reports

Two cases of spontaneous rupture of the spleen are reported: one in a case of infectious mononucleosis with splenomegaly, the other in a spleen with multiple hemangiomas. King, in 1941, presented the only other case of splenic rupture in mononucleosis reported in the literature. Both of the cases presented herein recovered following splenectomy.     

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.     

Spontaneous splenic rupture resulted from infectious mononucleosis

INTRODUCTIONInfectious mononucleosis is common among young adults and teenagers. However, spontaneous rupture of spleen secondary to IM is rare and it is the most frequent cause of death in infectious mononucleosis.PRESENTATION OF CASEA previously healthy 16-year-old girl presented with a one-week history of sore throat, non-productive cough, fever, malaise and a positive Monospot test. Prior to transfer to the hospital, she had two syncopal episodes and a complaint of abdominal pain at home. Clinical examination revealed that she was febrile and mildly tachycardic with an evidence of localised peritonism on her left upper quadrant. Urgent abdominal ultrasound and computed tomography scan showed subcapsular haematoma with a significant amount of complex fluid within the abdominal cavity, especially the left flank. Emergency laparotomy was performed and a moderate amount of haemoperitoneum was evacuated. The spleen was found grossly enlarged with a haematoma identified on the ruptured capsule. Splenectomy was performed and peritoneal cavity was washed out meticulously prior to the closure of the abdominal wall.DISCUSSIONDespite the fact that infectious mononucleosis is a self-limiting disease, it may cause serious and lethal complications. The best treatment of splenic rupture secondary to infectious mononucleosis has been controversial but it is mainly based on the haemodynamical status of the patient and the experience of the treating surgeon.CONCLUSIONSpontaneous rupture of spleen secondary to IM can be lethal in those patients with high possibility of deterioration with conservative management, thus timely surgical intervention is required.     

Spontaneous rupture of the spleen in infectious mononucleosis: a failed attempt at nonoperative therapy

Rupture of the spleen in infectious mononucleosis is a rare but potentially fatal complication. Once injured, the "pathologic" spleen may have limited reparative capabilities. In this situation, operative management seems to be the safer therapeutic approach.     

Rupture of the spleen in infectious mononucleosis: a critical review

Spontaneous rupture of the spleen in infectious mononucleosis is a well-known clinical phenomenon. However, when strict criteria concerning the presence or absence of trauma and the diagnosis of infectious mononucleosis are applied to the 107 cases in the world literature, only 18 true spontaneous ruptures are found. In these, the survival rate was 100%. In addition to pain referral to the left shoulder (Kehr's sign), right shoulder and scapular pain from diaphragmatic irritation, caused by free intraperitoneal blood, can be a valuable sign in determining splenic rupture. Because the spleen remains susceptible to rupture even after recovery based on all clinical, hematologic, and serological criteria, it is recommended that full normal activities not be resumed for two to three months by the nonathlete and for six months by the athlete.     

Case report of a young female with early presentation of spontaneous splenic rupture in infectious mononucleosis

Spontaneous splenic rupture is a well known, yet very rare complication of infectious mononucleosis with an estimated incidence of 0.06% to 0.5%. It primarily affects teenagers and young adults and is the leading cause of death in infectious mononucleosis. There is a 9% mortality rate associated with spontaneous splenic ruptures; in all lethal cases a rupture occurs within the first 10 days of symptoms onset from infectious mononucleosis. The present case report concerns a young female, who presented with abdominal pain, vomiting and positive Kehr’s sign two days after the onset of infectious mononucleosis symptoms. The patient was diagnosed with a spontaneous splenic rupture due to infectious mononucleosis and was treated operatively by laparotomy and splenectomy. The patient was successfully treated, and had no post operative complications.     

Occult rupture of the spleen

Five cases of occult or 'spontaneous' rupture of the spleen are described. Pathological examination of the spleen showed changes of infectious mononucleosis in 2 cases, Hodgkin's disease in 1, amyloidosis in 1 and in the remaining spleen no underlying disease process was seen. All 5 cases survived, and evidence from the literature suggests that this may have been in some measure due to the fact that prompt surgical treatment followed a correct preoperative diagnosis. The importance of awareness of the condition, radiological investigation and peritoneal lavage in reaching the correct diagnostic conclusion is discussed.     

Spontane Milzruptur bei infektiöser Mononucleose —Organerhaltende Operation mittels Fibrinklebung

Zusammenfassung Bei einer 16jährigen Patientin mit infektiöser Mononucleose trat am achten Krankheitstag eine spontane Milzruptur auf. Diese Komplikation ist selten; in der Literatur wurden bisher lediglich 38 Fälle gesicherter spontaner Milzrupturen bei infektiöser Mononucleose beschrieben. Diagnostik der Ruptur und die weitere Verlaufsbeobachtung erfolgten bei unserer Patientin sonographisch. Erstmals wurde bei diesem Krankheitsbild eine milzerhaltende Operation mittels Fibrinklebung der Rupturbereiche durchgeführt.

---

Spontaneous splenic rupture in infectious mononucleosis —Organ preserving operation by means of fibrin tissue adhesive

Summary We present the case of a 16-year-old female patient with infectious mononucleosis complicated by spontaneous splenic rupture on the eighth day of the disease. This event is seldom; only 38 cases of true spontaneous rupture of the spleen in infectious mononucleosis could be found when the literature was reviewed. The diagnosis of splenic rupture in our case was made by ultrasound, just as the further postoperative follow-up. For the first time the splenic lesion was successfully managed by application of fibrin tissue adhesive.

     

Hemolytic uremic syndrome linked to infectious mononucleosis

A 12-month-old boy developed a mild hemolytic uremic syndrome with no acute diarrheal prodrome. The typical clinical, hematological, and serological features of infectious mononucleosis were also noted. The clinical course of both hemolytic uremic syndrome and infectious mononucleosis was uneventful. A review of the literature disclosed that hemolytic uremic syndrome has been noted in two adolescents with infectious mononucleosis.     

Splenic injury: nonoperative management in three patients with infectious mononucleosis

Three patients with infectious mononucleosis and splenic injury were managed nonoperatively. Mechanisms of injury included significant left upper quadrant trauma during a football game in a 17-year-old boy, a minor fall in a 16-year-old girl, and no apparent trauma in the remaining patient, a 28-year-old man. All had significant abdominal pain and two were hypotensive upon admission. All had computerized tomographic scan documentation of splenic enlargement, significant injury, and free peritoneal blood. Paracentesis was not performed. Only the first patient received transfused blood. The hospitalization period ranged from nine to 14 days. Gradual and finally complete healing (return to normal size) was documented in all three patients. Follow-up is 66, 14, and 10 months. Although clearly controversial and not free from danger, successful nonoperative management of the injured enlarged spleen in select patients with mononucleosis is possible in an appropriate setting.     

THE MANAGEMENT OF SPLENIC RUPTURE IN INFECTIOUS MONONUCLEOSIS

Non-operative management of splenic trauma is now well established; however, the role of conservative management in spontaneous splenic rupture is undetermined. The leading cause of spontaneous splenic rupture is infectious mononucleosis. We report on the management of four patients with spontaneous rupture, in association with infectious mononucleosis. Three patients eventually required splenectomy, and one was successfully managed non-operatively. The comparative risks of operative and non-operative management are discussed. We believe that when splenic rupture complicates infectious mononucleosis, early splenectomy is the most appropriate management.     

Airway obstruction in infectious mononucleosis. A case report

A 3 1/2-year-old child with infectious mononucleosis developed upper airway obstruction because of enlarged tonsils and adenoids; the obstruction resolved spontaneously. The spectrum and management of airway obstruction in infectious mononucleosis is described.     

Management of blunt splenic injury in patients with concurrent infectious mononucleosis

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.     

Spontaneous splenic haematoma in a teenager with infectious mononucleosis

Spontaneous subcapsular splenic hematoma formation without rupture in infectious mononucleosis is a very unusual occurrence. Splenic rupture in infectious mononucleosis (Pfeiffer disease, or glandular fever) is a rare but life-threatening complication. A conservative management is successful in those patients in stable condition. We describe the presentation and the clinical progress of a case in whom a sudden enlargement in hematoma's diameter needed a splenectomy to avoid the risk of blood effusion in the abdominal cavity. The contribution of the sonographic examination and follow-up in the diagnosis of infectious mononucleosis is emphasised.     

Infectious mononucleosis with acute urinary retention

The second case of infectious mononucleosis presenting as acute urinary retention is reported. A discussion of the signs, symptoms, and laboratory findings in infectious mononucleosis is presented as well as a review of the literature pertaining to urologic complications of this disease.     

Transfusion-associated cytomegalovirus mononucleosis.

Transfusion-associated cytomegalovirus mononucleosis is generally considered only as a complication of extracorporeal circulation following cardiac surgery. Three cases following trauma were recognized in less than one year. Both massive and limited volume blood transfusions were involved. Hectic fever was a characteristic feature in these otherwise remarkably asymptomatic individuals, without the classic features of heterophile-positive infectious mononucleosis. Since the illness developed several weeks into the post-operative period after extensive thoracic or abdominal trauma surgery, the presence of an undrained abscess was naturally the major diagnostic concern. Atypical lymphocytosis, markers of altered immunity (cold agglutinins, rheumatoid factor) and moderate hepatic dysfunction were important laboratory clues. In one case, focal isotope defects in the spleen scan misleadingly suggested a septic complication. A false-positive monospot test initially obscured the correct serologic diagnosis in the same patient. Failure to consider this selflimited viral infection may be a critical factor leading to unnecessary surgery. Other viral agents capable of eliciting a similar syndrome are cited.     

Spontaneous splenic rupture in infectious mononucleosis

Spontaneous splenic rupture occurs in association with infectious mononucleosis. Three cases of serologically proven infectious mononucleosis complicated by spontaneous splenic rupture are described. In two, the diagnosis was confirmed preoperatively by abdominal computerized tomographic (CT) scan. Treatment by splenectomy was curative in all three patients. Infectious mononucleosis patients who have acute abdominal pain must be considered for potential splenic hemorrhage.     

Infectious mononucleosis. The spectrum of morphologic changes simulating lymphoma in lymph nodes and tonsils

Lymph-node and tonsillar biopsies occasionally are obtained from patients with the infectious mononucleosis syndrome secondary to Epstein-Barr viral infection, particularly if the clinical presentation is atypical and a viral etiology is not suspected. The presence of Reed-Sternberg-like cells in infectious mononucleosis resulting in confusion with Hodgkin's disease is well-known; however, similar difficulty in excluding a non-Hodgkin's lymphoma can be encountered. Eleven cases of reactive lymphoid hyperplasia with the morphologic features of infectious mononucleosis are reported, nine of which had documented Epstein-Barr viral infection. The spectrum of morphologic changes associated with Epstein-Barr viral infection is discussed, with emphasis on the features that permit their distinction from non-Hodgkin's lymphoma. Morphologic features mimicking lymphoma included extensive immunoblastic proliferations in sheets and nodules and marked cytologic atypia. Hodgkin's disease was simulated by the tendency in some cases for the atypical Reed-Sternberg-like cells to cluster about necrotic foci and to show pronounced cytologic atypia. Features permitting the distinction from non-Hodgkin's lymphoma included persistent reactive foci with the classic features of infectious mononucleosis, a polymorphous background of transformed lymphocytes rather than irregular or twisted lymphoid cells as seen in non-Hodgkin's lymphoma, and preservation of underlying reticulin architecture rather than destruction, even in cases with extensive immunoblastic proliferation. Hodgkin's disease was excluded by requiring strict criteria for Reed-Sternberg cells and noting the reactive background as inconsistent with Hodgkin's disease. Immunoperoxidase staining of seven of the cases with anti-Leu-M1 failed to demonstrate immunoreactivity of the Reed-Sternberg-like cells with this monoclonal antibody.