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Successful Conservative Treatment of Spontaneous Splenic Rupture in a 14 Year Old Female with Infectious Mononucleosis

Enrica Rossi¹, Cosimo Bleve¹, Marco Libanore², Andrea Franchella¹
¹Operative Unit of Pediatric Surgery, ²Operative Unit of Infectious Diseases
Arcispedale S. Anna, Ferrara, Italy

 

 

Correspondence

Enrica Rossi, MD
Operative Unit of Pediatric Surgery, Arcispedale S. Anna, C.so Giovecca 203; 44100 Ferrara
tel 0039 0532 236580; fax 0039 0532 247107
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Abstract

Spontaneous splenic rupture is an uncommon complication of infectious mononucleosis (IM) caused by rapid splenic enlargement due to lymphocytic infiltration of the capsule and vascular walls. The incidence of splenic rupture in patients with proven infectious mononucleosis (IM) is about 0.6-0.7%. As it is a potentially lethal complication, many surgeons favour total splenectomy to non-operative therapy as a mean of treatment in both adult and pediatric populations. We report a case of spontaneous splenic rupture in a 14-year-old female IM patient who recovered completely following conservative treatment and seriated hemodynamic and ultrasonographic monitoring.

Key words: infectious mononucleosis; spontaneous splenic rupture

  

Introduction

Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder which predominately affects teenagers and young adults [1]. Clinical manifestations of the disease comprise a triad of primary symptoms: sore throat, fever and lymphoadenopathy [2]. Hepathomegaly and splenomegaly are also common. Although the majority of IM patients recover without further problems, hematologic, splenic, neurologic, hepatic, renal, cardiac and/or pulmonary complications may occur on occasion. In most cases these complications can be successfully treated but mortality has been reported in literature [3, 4]. The most life-threatening complication of IM is almost certainly spontaneous splenic rupture which occurs in 0.1% up to 0.7% of cases [1-2]. In these cases rapid splenic enlargement due to lymphocytic infiltration of the capsule and vascular walls predispose the organ to rupture. This tends to occur spontaneously in the second or third week of illness [4-6] and is often accompanied by referred abdominal pain in the upper left quadrant which may be insidious or abrupt. On rare occasions abdominal pain is absent and the first manifestation of splenic rupture is hemodynamic shock making it a potentially lethal complication.

Case Report

A 14-year-old female was transferred to our Department following suspicions of splenic rupture. She had previously been recovered in the Pediatric Unit of a nearby hospital presenting IM (decrease of general conditions) and had been treated with claritromicine and prednisone. Serologic evaluation was positive for the Epstein-Barr virus. One week after hospitalization the patient referred sudden, diffuse and continuous abdominal pain. A US scan revealed splenomegaly (longitudinal splenic diameter >16 cm) with dishomogeneity of the lower pole parenchymal and a significant amount of opaque fluid present in both parietocolic sides and in the pelvis ( fig. 1). A CT- Scan was performed and revealed the presence of a large amount of fluid compatible with active splenic bleeding in the peritoneal cavity, mainly on the left side in correspondence with the lower pole of the spleen ( fig. 2). Hemoglobin was 10.5 g/dl (at the time of hospitalization was 13.2 g/dl); hematocrit was 31%; leukocyte count 29.6/cm3 with 55% lymphocytes.

spontaneous 1 spontaneous 2
Figure 1. US-scan revealing an important amount of perisplenic opaque fluid Figure 2. CT-scan showing a large amount of perihepatic and perisplenic fluid

The patient was transferred to our Department for surgical evaluation and upon arrival presented some pain but showed good hemodynamic conditions: her blood pressure was 122/70 mmHg, her pulse 105/min, her temperature was 39°C, her serum haemoglobin was 9.3 g/dl and hematocrit 29%; leukocytes were 23.9/cm3 with 27% lymphocytes.

Analgesic therapy with tramadol and paracetamol was commenced and antibiotic, corticosteroid and anti-acid therapy was continued. Infectologists proposed double antibiotic therapy with amoxicillin and claritromicin. The patient was carefully monitored for changes in blood pressure, pulse, diuresis, temperature. Hemoglobin fell from 9.3 g/dl to 8.2 g/dl after 8 hours but stabilized at 9.2 g/dl after 24 hours. Careful ultrasonographic monitoring was also carried out in order to evaluate changes in the quantity and type of intraperitoneal fluid present. The patient maintained good clinical conditions, good vital parameters and unvaried intraperitoneal fluid characteristics during the first week. After one week haemoglobin was 9.8 g/dl without blood transfusion, hematocrit 30%, leukocytes were 16.55/cm3. The transaminases also progressively decreased. Ultrasound revealed partial organization of the perisplenic hematoma. Two months after the acute episode, normalization of splenic parenchyma was shown upon US evaluation.

Discussion 

Non-operative management is nowadays the approach of choice in children with blunt splenic trauma when hemodynamic conditions are stable although overwhelming infection in splenectomized children is a significant and life-threating clinical entity. As long ago as 1968 the advantages of conservative treatment in splenic trauma were advocated [7] and the problem of overwhelming infection (OPSI) after splenectomy in childhood was emphasized in 1969 [2]. Though most infections occur within the first two years after splenectomy, up to a third may manifest themselves over five years later, and cases of fulminating infection have been reported more than 20 years after splenectomy [8]. This comports a mortality rate of about 50-70% so cannot be ignored. In the 50% of cases of IM the etiologic agent is Streptococcus Pneumoniae, in 25% of cases it is Hemofilus Influenzae or Neisseria Meningitidis and in the remaining 25% of cases gram-negatives like Pseudomonas and Escherichia Coli are responsible. Patients who undergo splenectomy for hematologic or neoplastic diseases are routinely vaccinated against the most important etiologic agents, and this reduces the risk of OPSI by 47% and mortality by 88%.

Although the risk of post-splenectomy sepsis in children has nowadays been minimized by vaccination, we have to consider that when urgent intervention is required and it is not possible to respect the correct timing of prophylaxis and immunization. Therefore, splenectomy tends to be avoided in children if the hemodynamic conditions are stable. Emergency splenectomy is however mandatory in some cases of spontaneous splenic rupture with hemodynamic instability. The literature states that arteriography with or without embolization of the splenic artery and conservative surgery sparing the splenic parenchyma should be considered in some cases [1-3] but no indication is cited for children or teenagers.

Conservative treatment of spontaneous splenic rupture in patients with hemodynamic stability requires hospitalisation, restriction of physical activity and careful monitoring of clinical and ultrasonographic parameters. The duration of hospitalisation depends upon the degree of the blunt trauma presented but has been reduced to 2 days for minor injuries (grade I) and to 5 days for severe injuries (grade IV-V). The duration of activity restriction suggested varies from 3 weeks for minor injuries to 6 weeks for severe injuries [7]. The total hospital stay for splenic blunt trauma also varies according to the surgical department involved and on the possibility or not of effective monitoring at the patient’s home [5].

Conclusion

Based on this case report and following a review of the literature we are of the opinion that careful clinical, laboratory and ultrasonographic monitoring are the gold standard in the management of spontaneous splenic rupture in the course of IM in children and young adults. They are reliable parameters in detection of any worsening in the clinical conditions, and thus splenic injury associated with IM does not exclude conservative treatment in spontaneous splenic rupture. US is a feasible and non-invasive imaging technique for monitoring splenic trauma in the post-acute phase and is useful for determining the degree and the evolution of the blunt trauma.

 

 

REFERENCES 

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