Epstein-Barr Virus-Associated Atraumatic Spleen Laceration Presenting with Neck and Shoulder Pain

Abstract

Patient: Male, 15Final Diagnosis: Infectious Mononucleosis induced spleen laceratioSymptoms: Fever • headache • neck pain and upper shoulder pain which was worse with flexion and extensionMedication: —Clinical Procedure: Splenic angiogram and proximal splenic artery embolization techniqueSpecialty: Critical Care MedicineObjective:Unusual clinical courseBackground:Infectious mononucleosis, caused by the Epstein-Barr virus (EBV), is a common infection with worldwide distribution; more than 90% of people have been infected by adulthood. One of the most feared, albeit rare, complications, occurring in less than 0.5% of those infected, is splenic injury or rupture.Case Report:A febrile 15-year-old male presented to the emergency department with the chief compliant of headache, neck pain, and upper shoulder pain. He did not recall any specific traumatic injury. His abdomen was soft, nondistended, and was tender in the right and left lower quadrants. Right lower quadrant ultrasound demonstrated non-visualization of the appendix, moderate right lower quadrant free fluid, and positive McBurney’s sign.CT of the abdomen and pelvis was ordered, which demonstrated moderate splenomegaly, with findings compatible with laceration through the anterior aspect of the spleen, with moderate hemoperitoneum. Monospot was negative and EBV panel demonstrated IGG negative, IGM positive, and, IGG negative.The patient was transferred to interventional radiology for a splenic angiogram and proximal splenic artery embolization. The angiogram demonstrated grade 3 laceration with moderate hemoperitoneum and no active extravasation or evidence of pseudoaneurysm. The patient was admitted and made a prompt recovery without any other sequelae.Conclusions:The presentation of splenic injury or rupture can vary; the patient may complain of abdominal pain or left upper quadrant pain, may exhibit referred left shoulder pain when the LUQ is palpated (Kehr’s Sign), or may exhibit hemodynamic instability. Given the spectrum of non-specific symptoms, diagnosing EBV-induced splenic laceration can be difficult.

Visceral Origin: An Underestimated Source of Neck Pain. A Systematic Scoping Review

“…The presence of muscle hypertonus, myofascial trigger points, and/or myofascial pain syndrome may increase symptoms during musculoskeletal activity. Similarly, pain modification related to movement and/or postures has also been described during the affectation of the spleen [97], gallbladder [72,98], kidney [99,100], and heart [15,101].…”

Spontaneous splenic rupture in a patient with infectious mononucleosis

“…The most common symptom to present with in a case of splenic rupture is abdominal pain (88%),4 more specifically left upper quadrant pain. Rarer presentations include pleuritic left-sided chest pain5 6 and left shoulder pain 7. The left shoulder pain is known as Kehr’s sign, and is a classic sign of a ruptured spleen, seen in 50% of cases 3.…”

Atraumatic splenic rupture secondary to Epstein-Barr virus infection

“…It classically presents with left upper quadrant pain radiating to the left shoulder tip, which can be elicited on palpation of the spleen, known as Kehr's sign 4 5. They may also present with haemodynamic compromise and anaemia.…”

“…Staging can be performed using the American Association for the Surgery of Trauma (AAST) splenic injury scale; however, in unstable patients, focused USS could be used with prompt surgical intervention 4 6. It can be managed conservatively and surgically.…”

“…It can be managed conservatively and surgically. Non-operative management is suggested in haemodynamically stable patients with low splenic injury scale grade, and there is increasing use of endovascular techniques such as splenic artery angiography with embolisation to allow preservation of the spleen 4 7 8. However, over half of them require surgical management and splenectomy.…”