Nonoperative Management of Spontaneous Splenic Rupture in Infectious Mononucleosis: The Role for Emerging Diagnostic and Treatment Modalities

Abstract

Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder affecting teenagers and young adults. Splenomegaly is a common manifestation of IM and results in a compromised organ that may rarely rupture spontaneously, with significant morbidity and mortality. The IM spleen should be protected from even minor trauma. Although traditional management of spontaneous splenic rupture in IM has been splenectomy, the role of nonoperative management is evolving. The advent of endovascular interventional modalities has augmented the physician's armamentarium in managing these patients nonoperatively. We report a case of spontaneous splenic rupture in a patient with IM managed conservatively with the aid of splenic angiography. The option of arteriography, with or without embolization, should be considered in the management of all patients with spontaneous splenic rupture in the setting of IM.

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

“…As the EBV infection progresses, a proliferation of mononuclear cells results, which collect within the lymphoid tissue. This includes the spleen, and as the spleen enlarges, the splenic capsule thins, which is seen in about 50% of patients [ 7 ]. A secondary complication from the reversible splenomegaly is rupture, as was noted in this case [ 7 , 8 ].…”

“…This includes the spleen, and as the spleen enlarges, the splenic capsule thins, which is seen in about 50% of patients [ 7 ]. A secondary complication from the reversible splenomegaly is rupture, as was noted in this case [ 7 , 8 ]. This relatively rare complication often presents with left upper quadrant abdominal pain, but this expected manifestation was not observed in the patient, perhaps secondary to his other distracting symptoms, the foremost being headache and neck pain, nor was any splenomegaly found on physical exam.…”

“…In severe cases, it would also be prudent to be prepared to administer blood products. Additional possible lab values abnormalities include elevated liver function studies, which are elevated in up to 90% of patients [ 7 ]. If clinical suspicion points toward a possible spleen injury, a bedside ultrasound serves as a rapid and sensitive modality for detection of free fluid, and is the test of choice in hemodynamically unstable patients.…”

“…CT scan is the recommended confirmatory test since it permits the clinician to grade the severity of splenic damage. Contrast-enhanced CT findings can include hemoperitoneum or contrast extravasation, lacerations, subcapsular or intraparenchymal hematomas, splenic hypodensity, and splenomegaly [ 7 ].…”

“…In cases of treatment failure and hemodynamic instability, surgical exploration is recommended. If possible, spleen preservation should be the ultimate goal if clinically feasible, given the long-term sequelae of asplenia [ 7 , 8 ]. Additional treatment should include discharge instructions to avoid exertional physical activities and contact sports until splenomegaly has resolved.…”