Splenic rupture and infectious mononucleosis

The Journal of Emergency Medune,

Vol. 7. pp. 471-475,

Printed In the USA

1989

SPLENIC RUPTURE AND INFECTIOUS Carl W. Konvolinka, *Department Repfir

MD, FACS,*vt

MONONUCLEOSIS

and Douglas B. Wyatt,

MD*

of Surgery, Conemaugh Valley Memorial Hospital, Johnstown, Pennsylvania, and tTemple University School of Medicine, Philadelphia address: Carl W. Konvolinka, MD, 1086 Franklin Street, Johnstown, PA 15905

IIIAbstract-Infectious mononucleosis is an acute viral illness associated with a high incidence of splenomegaly, although the incidence of splenic rupture is low. When rupture occurs, the mortality has been significant, presumably, because a history of trauma is not present. The spleen may be vulnerable to injury due to the histopathologic changes that occur as a result of this illness. Essentially all patients with spontaneous rupture related to infectious mononucleosis have epigastric or upper abdominal pain. The diagnosis of splenic rupture may be confirmed in a variety of ways. In those patients who are hemodynamically stable, CT scan, ultrasound, or radionuclide scan may aid in establishing the diagnosis. Selective splenic angiography is very accurate but has been largely abandoned because of the invasive nature of the study. Peritoneal lavage is efficacious in establishing the diagnosis in hemodynamically unstable patients. The treatment of choice, at this time, is splenectomy. Current interest in splenic salvage has resulted in reports of nonoperative therapy in stable patients and splenorrhaphy in one instance. Due to the extent of the histologic changes in the spleen, caution is urged in electing the conservative approach to this clinical situation.

associated with infectious mononucleosis may lead to a tragic outcome. Hallstrom and Bonnabeau (3) note a 30% mortality associated with rupture under these circumstances, presumably due to failure to establish the diagnosis. In contrast, Rutko (4) reported no mortality in 18 surgically treated cases of spontaneous splenic rupture in which the diagnosis was accurately established. The following report illustrates a typical case of spontaneous rupture of the spleen in a patient with documented infectious mononucleosis and no history of injury. CASE REPORT

BK was a 22-year-old white female with a 2-week history of fatigue, generalized weakness, sore throat, cervical lymphadenopathy, and splenomegaly. Laboratory studies indicated a positive monospot test and atypical lymphocytes in the peripheral smear. She was diagnosed as having infectious mononucleosis. On the 15th day of her illness, while resting at home, she developed epigastric and left upper quadrant pain followed by lightheadedness. There was no history of abdominal or chest injury in the previous 6 weeks, and her menstrual history was normal. She was taken to the office of her family physician who noted a blood pressure of 80150 with a pulse rate of 120 per minute. She was immediately brought to the emergency department where her blood pressure remained at 80150 with a pulse rate of 120/min. Her abdomen was noted to be moderately distended. Resuscitative measures were instituted and a diagnostic peritoneal lavage was immediately carried out that revealed, on initial aspiration, over 20 cc of unclotted blood. The lavage was terminated at that point. Because of the patient’s hemodynamic instability in spite of ade-

0 Keywords-infectious mononucleosis; splenomegaly; splenic rupture; spontaneous splenic rupture; splenectomy

INTRODUCTION Infectious mononucleosis is an acute viral illness that affects children and young adults. It is caused by Epstein-Barr virus and appears to be associated with splenomegaly in approximately half of the cases (1,2). While splenomegaly appears to be a common occurrence in mononucleosis, rupture, either spontaneous or due to trauma, occurs in less than 0.5 percent of all patients (1,2). Because any history of significant abdominal trauma is usually absent, failure to appreciate the significance of splenic hemorrhage

RECEIVED: ACCEPTED:

Copyright 0 1989 Pergamon Press plc

??

17 January 1989; FINAL SUBMISSION RECEIVED: 2 April 1989; 11April 1989 471

0736-4679/89

$3 .OO + .OO

472

Carl W. Konvolinka, Douglas B. Wyatt

quate resuscitative measures, she was taken immediately to the operating room and underwent exploratory laparotomy. A very large spleen was visualized with an extensive laceration deep into the parenchyma of the spleen. Eighteen hundred cc’s of free intraperitoneal blood were removed and a splenectomy accomplished. The specimen weighed 910 grams and contained large numbers of atypical lymphocytes in the sinusoids and infiltrating the adventitia of the splenic vessels. There was also extensive lymphocytic invasion of the capsule of the spleen. Following control of the hemorrhage, the patient became hemodynamically stable and had a benign postoperative course. She was discharged on the 7th postoperative day.

DISCUSSION Spontaneous rupture of the spleen associated with infectious mononucleosis was first described by King in 1941 (5). Since then, well over 100 cases of splenic rupture associated with mononucleosis have been reported although less than two dozen meet the strict criteria established by Orloff and Peskin (6) for classification as a spontaneous rupture. These criteria include no history of trauma within the 6-week period prior to the rupture, symptoms and signs compatable with mononucleosis, strict hematologic and serologic parameters confirming the diagnosis, and histologic changes in the spleen commonly associated with this illness. The patient described in this report meets all these criteria and can thus be classified as a spontaneous rupture of the spleen associated with infectious mononucleosis. Splenic rupture occurs most frequently from the 14th to the 28th day following onset of the illness (4,7). Abdominal pain, an infrequent complaint among patients with infectious mononucleosis, is seen in greater than 90% of those who develop splenic hemorrhage (8). The most common physical finding is tenderness, usually in the left upper quadrant or the epigastrium. Splenomegaly, noted in 50% of those with mononucleosis (2), appears to be universally associated with rupture. Although frank rupture is uncommon, the incidence of subcapsular hemorrhage is currently unknown. There are significant histopathologic changes that occur in the spleen. Bell and Mason (9) suggest that degeneration of follicular arteries, vasculitis of the larger veins, and capsular inflammation may result in a spleen highly vulnerable to rupture. This, splenomegaly coupled with the histologic changes in the spleen and capsule appear to

render it susceptible to injury from minor trauma. Spontaneous rupture, though rare, has been substantiated as well (5). The diagnosis of splenic rupture associated with infectious mononucleosis has been confirmed radiographically by computed tomography, ultrasound, and radionuclide scans. In the stable patient, computed tomography gives a reliable evaluation of the splenic architecture and may also detect evidence of free intraperitoneal fluid (10). Johnson et al. (11) reported three cases of splenic rupture diagnosed and followed nonoperatively by ultrasound. Peters and Gordon (12) also report the use of ultrasound to follow a case initially diagnosed by computed tomography. In addition, Beyer et al. found ultrasound to be reliable in the evaluation of 1000 cases of abdominal trauma including splenic injury (unpublished observations). Vezina et al. (13) have successfully utilized radionuclide scans to detect evidence of splenic injury. Others feel the technique is as effective and sensitive as computed tomography (14). Of the three radiologic modalities, computed tomography appears to be most frequently recommended for evaluation of splenic injury. Kaufman et al. (15) conducted a prospective evaluation of CT, radionuclide scan, and sonography in 24 cases of splenic trauma in children. Computed tomography (CT scan) had no false negatives, radionuclide scans 3, and the ultrasound 12, suggesting the superiority of CT scan. Selective splenic angiography is very accurate but has largely given way to other modalities that are less invasive (16). Unstable patients, on the other hand, require that the diagnosis be established without delay. Peritoneal lavage is the most direct method of reliably detecting blood in the peritoneal capacity. However, peritoneal lavage will not detect the rare case of hemorrhage confined to the lesser sac (16). In such instances, evidence of continuing blood loss will lead to laparotomy and the establishment of the correct diagnosis. The recommended treatment for a spontaneously ruptured spleen associated with infectious mononucleosis has been splenectomy (4). This approach has achieved a high salvage rate. However, because of more recent concern for postsplenectomy sepsis and splenic salvage, alternative approaches have been reported. Kurchin and Yellin (17) accomplished successful splenorrhaphy following traumatic laceration of the spleen in a patient with infectious mononucleosis. The laceration was only 3 cm in length. Caution should be used in electing this approach in any but the most superficial injuries. Johnson et al. (11) report three cases of nonoperative management al-

473

Splenic Rupture-Mononucleosis

though only one of the three patients had hypotension and required tranfusion. This approach may be appropriate in the stable patient with splenomegaly and evidence suggestive of subcapsular hemorrhage but is contraindicated in the more extensive injury since past experience demonstrates excellent results using splenectomy and delay in surgical intervention appears responsible for most mortality (18). Reimplantation of a segment of the spleen following splenectomy has also been considered. However, postsplenectomy sepsis has been reported in patients with autotransplanted splenic tissue (19). Maintenance of immunocompetence requires a minimum of one-third of the splenic mass (20) along with its arterial blood supply (21). The role of splenorrhaphy is not clear primarily because of the histopathology of the spleen involved in infectious mononucleosis. The inflammatory infiltrate present in the parenchyma and capsule may render the spleen vulnerable to further hemorrhage following repair. More experience with splenorrhaphy in this clinical situation is required before it can be recommended as an acceptable alternative to splenectomy. Based on current understanding of this problem,

INFECTIOUS

any patient with infectious mononucleosis and splenomegaly who develops epigastric or left upper quadrant pain should have either a CT scan, radionuelide scan, or ultrasound study of the abdomen. If splenic subcapsular hemorrhage is detected and the patient is hemodynamically stable, a course of close observation may be elected rather than surgery until the symptoms and splenomegaly have resolved. One who becomes hemodynamically unstable or requires more than two units of packed red cells would be a candidate for laparotomy (Figure 1). Patients who are initially unstable should have peritoneal lavage to confirm the presence or absence of intraperitoneal hemorrhage followed by immediate laparotomy if positive (Figure 2). Individuals not requiring operative intervention should convalesce until all signs of the disease, including splenomegaly, have disappeared. It is suggested that patients should abstain from normal activities for 2 months after recovery and from athletic activities for 4 months (4). On the other hand, Hoagland and Henson (22) found no splenic ruptures in 200 West Point cadets who, if fully recovered, resumed normal activity 4 weeks after onset of symptoms.

MONONUCLEOSIS

SPLENOMEGALY, UPPER ABDOMINAL HEMODYNAMICALLY STABLE

CT SCAN, ULTRASOUND,

F~ADI~NU~LIDE

PAIN,

SCAN

1 POSITIVE

I NEGATIVE

I

ADMIT

1

STABLE 1 OBSERVE I

I ‘UNSTABLE

OR BLOOD LOSS GREATER THAN TWO UINTS PACKED RED CELLS

STOP I LAPAROTMY Figure 1. Decision tree for hemodynamically stable patient with mononucleosis, splenomegaly, and upper abdominal pain.

I LAPAROTOMY

I

4 CONSIDER OTHER ETIOLOGY

I

1 NEGATIVE

4

LAPAROTOMY

POSITIVE

1

POSITIVE

I

4

NEGATIVE

1

1 CONSIDER OTHER ETIOLOGY OR LAPAROTOMY

NEGATIVE

CT SCAN, RADIONUCLIDE SCAN, OR ULTRASOUND

PERITONEAL LAVAGE

I

Figure 2. Decision tree for hemodynamically unstable patient with mononucleosis, splenomegaly, and upper abdominal pain.

1 OBSERVE

I CONTlkUED BLOOD LOSS

I

STALLE

I POSITIVE

OBSERVE

1

CT SCAN RADIONUCLIDE SCAN OR ULTRASOUND

I

STAtiLE

I

I RESUSCITATE

SPLENOMEGALY, UPPER ABDOMINAL PAIN, HEMODYNAMICALLY UNSTABLE

475

Splenic Rupture-Mononucleosis

REFERENCES 1. Murray BJ. Medical complications of infectious mononucleosis. Am Fam Physician. 1985;30:195-9. 2. Shurin SB. Infectious mononucleosis. Pediatr Clin N Am. 1979;26:315-26. 3. Hallstrom SW, Bonnabeau RC. Rupture of the spleen in infectious mononucleosis. Am Fam Physician. 1981;24:135-6. 4. Rutkow IM. Rupture of the spleen in infectious mononucleosis. Arch Surg. 1978;113:718-20. 5. King RB. Spontaneous rupture of spleen in infectious mononucleosis. N Engl J Med. 1941;224:1058-60. 6. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen-a surgical enigma. Surg Gynecol Obstet. 1958;106:111. 7. Sakulsky SB, Wallace RB, Silverstein MN. Ruptured spleen in infectious mononucleosis. Arch Surg. 1967;94:349-52. 8. Hoagland RJ. Infectious Mononucleosis. New York: Grune and Stratton; 1967;52-68. 9. Bell JS, Mason JM. Sudden death due to spontaneous rupture of the spleen from infectious mononucleosis. J Forensic Sci. 1980;25:20-4. 10. Frecentese DF, Cogbill TH. Spontaneous splenic rupture in infectious mononucleosis. Am Surg. 1987;53:521-3. 11. Johnson MA, Cooperberg PL, Boisvert J, Stoller JL, Winrob H. Spontaneous splenic rupture in infectious mononucleosis sonographic diagnosis and follow-up. AJR. 1981;136:11 l-4. 12. Peters RM, Gordon LA. Nonsurgical treatment of splenic hemorrhage in an adult with infectious mononucleosis-case

report and review. Am J Med. 1986;80:123-5. 13. Vezina WC, Nicholson RL, Cohen P, Chamberlain MJ. Radionuclide diagnosis of splenic rupture in infectious mononucleosis. Clin Nucl Med. 1984;9:341-4. 14. Lutzker LG. Radionuclide imaging of the injured spleen and liver. Seminars in Nuclear Medicine. 1983;13:184-98. 15. Kaufman RA, Towbin R, Babcock DS, et al. Upper abdominal trauma in children: imaging evaluation. AJR. 1984;142:44960. 16. Aung MK, Goldberg M, Tobin MS. Splenic rupture due to infectious mononucleosis, normal selective arteriogram and peritoneal lavage. JAMA. 1978;240:1752-3. 17. Kurchin A, Yellin. Splenorrhaphy in a patient with splenomegaly. Arch Surg. 1982;117:509. 18. Alberty R. Surgical implications of infectious mononucleosis. Am J Surg. 1981;141:559-61. 19. Moore GE, Stevens RE, Moore EE, Aragon GE. Failure of splenic implants to protect against fatal post splenectomy infection. Am J Surg. 1983;146:413-4. 20. Van Wyck DB, Witte MH, Witte CL, Thies AC Jr. Critical splenic mass for survival from experimental pneumococcemia. J Surg Res. 1980;28:14-7. 21. Horton J, Ogden ME, Williams S, Coln D. The importance of splenic blood flow in clearing pneumococcal organisms. Ann Surg. 1982;195:172-6. 22. Hoagland RJ, Henson HM. Splenic rupture in infectious mononucleosis. Ann Int Med. 1952;46:1184-6.