Association of Splenic Rupture and Infectious Mononucleosis: A Retrospective Analysis and Review of Return-to-Play Recommendations

Abstract

Background: Infectious mononucleosis is typically a self-limited disease commonly affecting young adults. Splenic rupture is a rare but serious complication affecting 0.1% to 0.5% of patients with mononucleosis. Current guidelines (based on published case reports) recommend complete activity restriction for 3 weeks after onset of mononucleosis symptoms to reduce rupture risk. We examined actual timing of mononucleosis-associated splenic injury using a large repository of unpublished patient data. Hypothesis: The risk of splenic injury after infectious mononucleosis will remain elevated longer than previously estimated. Study Design: Retrospective case series. Level of Evidence: Level 4. Methods: The Military Health System Management Analysis and Reporting Tool (M2) was used to conduct a retrospective chart review. Coding records of TRICARE beneficiaries aged 5 to 65 years between 2006 and 2016 were screened. Patients diagnosed with both splenic injury and mononucleosis-like symptoms were identified, and their medical records were reviewed for laboratory confirmation of infection and radiographically evident splenic injury. Results: A total of 826 records of splenic injury were found in M2. Of these, 42 cases met the study criteria. Mean time to splenic injury was 15.4 (±13.5) days. Only 73.8% (n = 31) of injuries occurred within 21 days, and 90.5% (n = 38) of splenic injuries occurred within 31 days of symptom onset. Conclusion: A substantial number of splenic injuries occur between 21 and 31 days after symptom onset. While most splenic injuries were atraumatic, consideration should be given to extending return-to-play guidelines to 31 days after symptom onset to minimize risk. Risk of chronic pain after splenic injury may be higher than previously believed. Clinical Relevance: The risk for postmononucleosis splenic injuries remains elevated longer than current guidelines suggest. Restricting activity for 31 days after mononucleosis symptom onset may reduce the risk of splenic injury.

Spontaneous Spleen Rupture: An Unexpected Consequence of Infectious Mononucleosis - A Case Report

“…Spontaneous spleen rupture (SSR) is a well-known but serious complication associated with infectious mononucleosis (IM). Its frequency varies between 0.1 to 0.5% (Sylvester et al, 2019;Bartlett et al, 2016). HSM almost always precedes SSR (Hosey et al, 2008).…”

“…SM and its spontaneous rupture is most often associated with IM caused by EBV) (Renzulli et al, 2009;Ishii et al, 2019;Ebell et al, 2016), which is the leading cause of SSR of infectious origin (Renzulli et al, 2009). SSR secondary to IM affects 2.5 to 4 times more males than females (2.5-4H: 1F) (Sylvester et al, 2019;Bartlett et al, 2016), and 95% of them are under 35 year-old (Bartlett et al, 2016).…”

“…In addition, when serology tests are positive for both viral capsid antigen (VCA) IgM (EBV) and CMV IgM, the latter positivity is often a false positive result resulting from antigenic cross-reactivity (Sohn et al, 2018). In most cases (88%), the finding of SM (with or without rupture) should prompt a search for IM (Sylvester et al, 2019).…”

“…To evoke the diagnosis of SSR, there should be no notion of trauma within the last 6 weeks preceding the rupture (Bartlett et al, 2016). The mean period of time between the onset of symptoms of IM and SSR is 14 days (Sylvester et al, 2019;Bartlett et al, 2016) with a range up to 8 weeks (Bartlett et al, 2016). Of note, SSR occurs within 31 days In 90 % of the cases (Sylvester et al, 2019), a period during which it is recommended to avoid sport activity.…”

“…The mean period of time between the onset of symptoms of IM and SSR is 14 days (Sylvester et al, 2019;Bartlett et al, 2016) with a range up to 8 weeks (Bartlett et al, 2016). Of note, SSR occurs within 31 days In 90 % of the cases (Sylvester et al, 2019), a period during which it is recommended to avoid sport activity. Bartlett et al, are even more drastic, increasing this recommendation up to 8 weeks (Bartlett et al, 2016).…”