Conservative
Management of Splenic Infectious Mononucleosis By Janice
L. Pasieka Calgary,
Injury
in
and Roy M. Preshaw Alberta
p Splenic rupture, in association with mononucleosis, can be lethal. Most reported cases of splenic rupture in patients with mononucleosis have not responded to conservative splenic preserving measures and have resulted in splenectomy. We report a case of traumatic splenic disruption in a patient with mononucleosis in whom conservative management was successful. We recommend consideration of splenic preservation measures in patients with mononucleosis and splenic disruption, if the patient is stable and meets other criteria of conservative management. Copyright 8 7992 by W. t3. Saunders Company INDEX WORDS: Mononucleosis,
traumatic
splenic injury.
I
N THE LAST decade the initial management of splenic injury in children has been conservative, with bedrest, blood transfusion, and close observation.‘” This treatment has also been successful in adults.4.5 There are many reported cases of both spontaneous and traumatic rupture of the spleen in patients with mononucleosis.“’ Some have suggested that conservative management should not be attempted when a diseased spleen is damaged, perhaps because pathological tissue would not heal so readily.’ One case has been reported of successful conservative management of traumatic splenic injury in a patient with mononucleosis,9 and we report another here.
CASE
REPORT
A previously healthy 17-year-old boy was injured in a fall while competing in a local ski jumping contest. There was no loss of consciousness. He complained of a painful swollen nose when he was first examined. The patient was transferred in stable condition to hospital, and when examined was alert, complaining of left shoulder discomfort, and had an obvious fractured nose. He appeared stable hemodynamically: blood.pressure 130/60 mm Hg supine and 120/60 mm Hg sitting; pulse 74 beats/min supine and 80 beats/min sitting. Chest was clear to auscultation. The abdomen was soft, but there was tenderness and guarding in the left upper quadrant. Bowel sounds were scant. Diffuse lymphadenopathy was noted in the groins, axilla, and neck. He gave a history of a febrile illness and sore throat for 3 weeks prior to this incident. Admission laboratory data included a hemoglobin of 144 g/L, and WBC 17,000 x 106/L. Computed tomography (CT) scan of the abdomen (Fig 1) demonstrated marked disruption of spleen, with some intraabdominal free fluid. The patient remained stable, and was admitted to an intensive care unit. Two days after his admission to hospital, a monospot test was positive. He was treated with bed rest. He remained stable, and no blood transfusion was required. By day 10 his abdominal examination was normal. A repeat CT scan showed mild improvement in the splenic disruption. He was then discharged home with a hemoglobin of 135 g/L. The patient returned to normal athletic activity after several Journal of Pediatric Surgery, Vol27, No 4 (April), 1992: pp 529-530
Fig 1. CT scan of upper abdomen (A) on day of injury, (6) 10 days later, and (C) 1 year later.
From the Division of General Surgery, University of Calgary, Calgary, Alberta. Address reprint requests to Roy M. Preshaw, MD, Room 1701, Health Sciences Bldg, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4NI, Canada. Copyright B 1992 by W.B. Saunders Company 0022-3468192/2704-0031$03.00/0 529
PASIEKA AND PRESHAW
530
months. A repeat CT scan at 1 year demonstrated normal size and contour (Fig 1).
a spleen of
DISCUSSION
There are numerous reported cases of spontaneous splenic rupture in patients with mononucleosis6z7 as well as several cases of traumatic rupture of the spleen in this condition.‘-” In each case, splenectomy was required, except for one subject in whom splenorraphy was sufficient.” Infectious mononucleosis produces pathological changes in the spleen most pronounced at 14 to 28 days after the onset of symptoms. It is during this period that the spleen is most susceptible to rupture.” Attempts to preserve the injured spleen, especially in children, have been widely accepted, primarily because of the life-long risk of overwhelming sepsis
after splenectomy.” However, little is known about the ability of an abnormal spleen to respond to such conservative measures. Some have recommended splenectomy for a ruptured spleen in mononucleosis, arguing that a diseased spleen may not have a normal ability to heal spontaneously.* Our case demonstrates that a spleen that has been massively disrupted can heal in mononucleosis, with no visible deformity on CT scan at 1 year. Conservative management of splenic injury has been reserved for those patients who remain stable under close observation in an intensive care unit setting, and in whom no other intraabdominal injuries are suspected, This case suggests that the same criteria may be applied to patients with traumatic splenic injury in mononucleosis.
REFERENCES 1. Wesson DE, Filler RM, Ein SH, et al: Ruptured spleenWhen to operate? J Pediatr Surg l&324-326,198l 2. King DR, Lobe TE, Haase GM, et al: Selective management of injured spleen. Surgery 90:677-682, 1981 3. Buykunal C, Danismend N, Yeker D: Spleen-saving procedures in pediatric splenic trauma. Br J Surg 74:350-352,1987 4. Moss JF, Hopkins WM: Non-operative management of blunt splenic trauma in the adult. A community hospital’s experience. J Trauma 27:315-317,1987 5. Wigg JN: Splenic trauma and overwhelming postsplenectomy infection. Br J Surg 74:310-313,1987 6. Rutkow IM: Rupture of the spleen in infectious mononucleosis: A critical review. Arch Surg 113:718-720, 1978 7. Frecentese DE, Cogbill TH: Spontaneous splenic rupture in infectious mononucleosis. Am Surg 53:521-523, 1987
8. McLean ER, Diehl W, Edoga JK. et al: Failure of conservative management of splenic rupture in a patient with infectious mononucleosis. J Pediatr Surg 22:1034-1035. 1987 9. Wallman P, Habliitzel K, Bandenbacher R. et al: [Traumatic splenic rupture in infectious mononucleosis: Spleen preserving therapy.] Schweiz Rundsch Med Prax 76:1260-1261, 1987 10. Kurchin A, Yellin JA: Splenorraphy splenomegaly. Arch Surg 117:509, 1982
in a patient with
11. Sakalsky SB, Wallace RB, Silverstein MN. et al: Ruptured spleen in infectious mononucleosis. Arch Surg 94:349-352, 1967 12. DiCataldo A, Puleo S, Lidestri A, et al: Splenic trauma and overwhelming post splenectomy infection. Br J Surg 73:343-345, 1987
Management of Splenic Infectious Mononucleosis By Janice
L. Pasieka Calgary,
Injury
in
and Roy M. Preshaw Alberta
p Splenic rupture, in association with mononucleosis, can be lethal. Most reported cases of splenic rupture in patients with mononucleosis have not responded to conservative splenic preserving measures and have resulted in splenectomy. We report a case of traumatic splenic disruption in a patient with mononucleosis in whom conservative management was successful. We recommend consideration of splenic preservation measures in patients with mononucleosis and splenic disruption, if the patient is stable and meets other criteria of conservative management. Copyright 8 7992 by W. t3. Saunders Company INDEX WORDS: Mononucleosis,
traumatic
splenic injury.
I
N THE LAST decade the initial management of splenic injury in children has been conservative, with bedrest, blood transfusion, and close observation.‘” This treatment has also been successful in adults.4.5 There are many reported cases of both spontaneous and traumatic rupture of the spleen in patients with mononucleosis.“’ Some have suggested that conservative management should not be attempted when a diseased spleen is damaged, perhaps because pathological tissue would not heal so readily.’ One case has been reported of successful conservative management of traumatic splenic injury in a patient with mononucleosis,9 and we report another here.
CASE
REPORT
A previously healthy 17-year-old boy was injured in a fall while competing in a local ski jumping contest. There was no loss of consciousness. He complained of a painful swollen nose when he was first examined. The patient was transferred in stable condition to hospital, and when examined was alert, complaining of left shoulder discomfort, and had an obvious fractured nose. He appeared stable hemodynamically: blood.pressure 130/60 mm Hg supine and 120/60 mm Hg sitting; pulse 74 beats/min supine and 80 beats/min sitting. Chest was clear to auscultation. The abdomen was soft, but there was tenderness and guarding in the left upper quadrant. Bowel sounds were scant. Diffuse lymphadenopathy was noted in the groins, axilla, and neck. He gave a history of a febrile illness and sore throat for 3 weeks prior to this incident. Admission laboratory data included a hemoglobin of 144 g/L, and WBC 17,000 x 106/L. Computed tomography (CT) scan of the abdomen (Fig 1) demonstrated marked disruption of spleen, with some intraabdominal free fluid. The patient remained stable, and was admitted to an intensive care unit. Two days after his admission to hospital, a monospot test was positive. He was treated with bed rest. He remained stable, and no blood transfusion was required. By day 10 his abdominal examination was normal. A repeat CT scan showed mild improvement in the splenic disruption. He was then discharged home with a hemoglobin of 135 g/L. The patient returned to normal athletic activity after several Journal of Pediatric Surgery, Vol27, No 4 (April), 1992: pp 529-530
Fig 1. CT scan of upper abdomen (A) on day of injury, (6) 10 days later, and (C) 1 year later.
From the Division of General Surgery, University of Calgary, Calgary, Alberta. Address reprint requests to Roy M. Preshaw, MD, Room 1701, Health Sciences Bldg, University of Calgary, 3330 Hospital Dr NW, Calgary, Alberta T2N 4NI, Canada. Copyright B 1992 by W.B. Saunders Company 0022-3468192/2704-0031$03.00/0 529
PASIEKA AND PRESHAW
530
months. A repeat CT scan at 1 year demonstrated normal size and contour (Fig 1).
a spleen of
DISCUSSION
There are numerous reported cases of spontaneous splenic rupture in patients with mononucleosis6z7 as well as several cases of traumatic rupture of the spleen in this condition.‘-” In each case, splenectomy was required, except for one subject in whom splenorraphy was sufficient.” Infectious mononucleosis produces pathological changes in the spleen most pronounced at 14 to 28 days after the onset of symptoms. It is during this period that the spleen is most susceptible to rupture.” Attempts to preserve the injured spleen, especially in children, have been widely accepted, primarily because of the life-long risk of overwhelming sepsis
after splenectomy.” However, little is known about the ability of an abnormal spleen to respond to such conservative measures. Some have recommended splenectomy for a ruptured spleen in mononucleosis, arguing that a diseased spleen may not have a normal ability to heal spontaneously.* Our case demonstrates that a spleen that has been massively disrupted can heal in mononucleosis, with no visible deformity on CT scan at 1 year. Conservative management of splenic injury has been reserved for those patients who remain stable under close observation in an intensive care unit setting, and in whom no other intraabdominal injuries are suspected, This case suggests that the same criteria may be applied to patients with traumatic splenic injury in mononucleosis.
REFERENCES 1. Wesson DE, Filler RM, Ein SH, et al: Ruptured spleenWhen to operate? J Pediatr Surg l&324-326,198l 2. King DR, Lobe TE, Haase GM, et al: Selective management of injured spleen. Surgery 90:677-682, 1981 3. Buykunal C, Danismend N, Yeker D: Spleen-saving procedures in pediatric splenic trauma. Br J Surg 74:350-352,1987 4. Moss JF, Hopkins WM: Non-operative management of blunt splenic trauma in the adult. A community hospital’s experience. J Trauma 27:315-317,1987 5. Wigg JN: Splenic trauma and overwhelming postsplenectomy infection. Br J Surg 74:310-313,1987 6. Rutkow IM: Rupture of the spleen in infectious mononucleosis: A critical review. Arch Surg 113:718-720, 1978 7. Frecentese DE, Cogbill TH: Spontaneous splenic rupture in infectious mononucleosis. Am Surg 53:521-523, 1987
8. McLean ER, Diehl W, Edoga JK. et al: Failure of conservative management of splenic rupture in a patient with infectious mononucleosis. J Pediatr Surg 22:1034-1035. 1987 9. Wallman P, Habliitzel K, Bandenbacher R. et al: [Traumatic splenic rupture in infectious mononucleosis: Spleen preserving therapy.] Schweiz Rundsch Med Prax 76:1260-1261, 1987 10. Kurchin A, Yellin JA: Splenorraphy splenomegaly. Arch Surg 117:509, 1982
in a patient with
11. Sakalsky SB, Wallace RB, Silverstein MN. et al: Ruptured spleen in infectious mononucleosis. Arch Surg 94:349-352, 1967 12. DiCataldo A, Puleo S, Lidestri A, et al: Splenic trauma and overwhelming post splenectomy infection. Br J Surg 73:343-345, 1987
