CASE REPORT
infectious mononucleosis; splenic abscess
RupturedSplenic Abscess Secondary to Infectious Mononucleosis
From the Department of Emergency Medicine, Gaston Memorial Hospital, Gastonia, North Carolina. Received for publication December 26, 1991. Revision received April 20, 1992. Accepted for publication May 8, 1992.
Kevin B O'Dell, MD Ronald S Gordon, MD
A 24-year-old woman with a recent diagnosis of infectious mononucleosis presented with fever and left upper quadrant pain. Abdominal computed tomography revealed a splenic abscess that at laparotomy was found to have ruptured. This case illustrates a rare cause of splenic abscess and a rare complication of infectious mononucleosis. [O'Dell KB, Gordon RS: Ruptured splenic abscess secondary to infectious mononucleosis. Ann EmergMed September 1992;21:1160-1162.] INTRODUCTION Splenic abscess is a r a r e entity with multiple etiologies. Fewer than 400 cases are described in the medical literature despite population-based autopsy studies that describe an incidence of 0.26% to 0.67%. 1-5 We present the r a r e association of infectious mononucleosis complicated by splenic abscess.
CASE
REPORT
A 24-year-old woman presented to the emergency d e p a r t m e n t with a three-day history of malaise, fever, and left upperq u a d r a n t pain. Two weeks earlier, she had had pharyngitis and right pleuritic chest pain. At that time, a positive heterophil agglutination resulted in the diagnosis of infectious mononucleosis. At the time of presentation, she denied nausea, vomiting, d i a r r h e a , fever, chills or hematochezia. She also denied IV drug abuse, ethanol abuse, or abdominal trauma. Physical examination revealed a thin woman in mild distress. Blood pressure was 110/68 mm Hg in both arms; pulse, 102; oral temperature, 36.8 C; and respirations, 18. Orthostatics were positive with a pulse rise of 30. The p h a r y n x , tympanic membranes, and sclera were u n r e m a r k a b l e . The neck was supple without lymphadenopathy. Cardiovascular examination revealed a regular tachycardic rate and r h y t h m without m u r m u r or gallop. The lungs were clear. Abdominal examination revealed moderate left u p p e r - q u a d r a n t tenderness without r e b o u n d , guarding, or distension. Bowel sounds were normoactive. The inferior pole of the spleen was palpable, and no a b n o r m a l pulsations were appreciated. The stool was guaiac negative. Gynecologic examination revealed no cervical motion tenderness or palpable masses. P e r i p h e r a l pulses were bounding and equal. The mental status and neurologic examinations were normal.
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The chest and upright abdominal radiographs were normal. The ECG showed a sinus tachycardia without ischemia or prior infarction. Laboratory results included a hemoglobin of 11.5 g/dL; hematocrit, 34.6%; leukocyte count, 16,200/ram 3 with 35% neutrophils, 26% lymphocytes, and 35% bands; platelets, 400,000/ram3; serum sodium, 139 mEq/L; potassium, 3.7 mEq/L; chloride, 100 mEq/L; COx, 25 mEq/L; glucose, 100 mg/dL; blood urea nitrogen, 6 mg/dL; creatinine, 0.7 mg%; amylase, 37 dye units/dL; and a negative urine B-HCG. A repeat oral temperature was 40 C two hours later. Abdominal examination at that time revealed severe left upper-quadrant tenderness with voluntary guarding and rebound tenderness. Surgical consultation was obtained for a presumed diagnosis of splenic abscess or infected splenic hematoma. Blood and urine cultures were performed, and aggressive crystalloid hydration and IV cefuroxime were administered. The surgical consultant requested a computed tomography scan of the abdomen that revealed a low-density lesion measuring 4 × 5 cm in the lateral aspect of the spleen, as well as borderline splenomegaly (Figure). The splenic cyst was thought to be consistent with a congenital cyst, hematoma, or abscess. Emergency exploratory laparotomy showed an enlarged spleen with a 4-cm ruptured abscess that had adhered to the tail of the pancreas and transverse mesoeolon. A splcnectomy, hepatic needle biopsy, and abscess cultures were performed. Two Jackson-Pratt drains were placed, and vigorous intraperitoneal irrigation was performed. Pneumococeal polyvalent vaccine was also administered. Intraoperative cultures grew Fusobacterium nucleatum, which was treated with the IV regimen of ampicillin, gentamicin, and clindamycin postoperatively. Pathology revealed splenic red pulp infiltration by atypical lymphocytes and plasma cells as well as a mild mononuclear hepatitis, both consistent with Epstein-Barr viral infection. The patient's postoperative course was complicated by a severe pancreatitis requiring three weeks of central hyperalimentation. A left subphrenic abscess developed and required percutaneous drainage ten days after splenectomy. The patient was discharged on postoperative day 31 tolerating clear liquids.
oxygen delivery, predisposing to abscess formation, a Immunodeficiency causes include immunosuppressiye drugs, diabetes mellitus, IV drug abuse, and AIDS. 1,3,9 Splenic abscess associated with infectious mononucleosis has been reported previously in a single case report. 7 Abdominal complications of infectious mononucleosis include splenic rupture, hepatitis, mesenteric adenitis, pancreatitis, and transient malabsorption, lO Left lower-lobe pneumonia secondary to Epstein-Barr virus infection also may produce abdominal complaints. The clinical presentation of splenic abscess is often subtle, with pain being the most frequent symptom. 11 The pain, usually pleuritic, may be in the left flank, left chest, left upper and lower abdomen, or left shoulder. Left upperquadrant tenderness is seen in 40% and splenomegaly in 50% of patients.l,11,12 Fever and leukocytosis is seen in up to 80% of patients, with positive blood cultures in 50% to 60%. 1,13 Organisms cultured from splenic abscesses include Staphylococcus aureus, Streptococcus moniliformis, and Gram-negative bacilli, most commonly Escherichia coli. 1,8,13,14 Mycobacteria and fungal infection are increasingly seen, with a 25% fungal etiology in one recent review. 9 Plain abdominal radiographs may show a left upperquadrant mass effect or extra-alimentary gas. Plain chest radiographs show left hemidiaphragm elevation with or without a pleural effusion in up to 80%.13,15 Ultrasound, gallium, indium, and liver-spleen scans have been used previously to detect splenic abscesses, but computed tomography has demonstrated a sensitivity and specificity rate of 90% to 95%. 16,17 In a recent series, the use of computed tomography for earlier diagnosis and aggressive antibiotic therapy decreased mortality to 10%. 7 Splenectomy remains the procedure of choice for bacterial splenic abscesses. Select patients may be managed with computed tomography-gnided percutaneous drainage, especially Figure.
Computed tomography scan showing splenic abscess
DISCUSSION
Splenic abscess remains a rare entity with mortality rates as high as 40%, despite appropriate antibiotic therapy. 3 The causes of splenic abscesses may be grouped into five categories: contiguous infection, metastatic infection (embolic infectious), embolic noninfectious events, trauma, and immunodeficiency. 1,3,6 Of the embolic infectious variety, bacterial endocarditis is the most common focus. Abscess formation after trauma may be seen weeks or months later. 7 Embolic noninfectious causes such as hemoglobinopathies and hematologic malignancies decrease splenic perfusion and
SEPTEMBER 1992
21:9
ANNALS OF EMERGENCY MEDICINE
1 1 6 1/ 1 6 5
SPLENIC RUPTURE O'DeU & Gordon
those with unilocular abscesses with weU-deFmed walls and nonseptated fluid collections. Suspected abscess r u p t u r e , multiple or muhilocular abscesses, p e r i h i l a r abscesses, a n d bleeding diatheses are relative contraindications to percutaneous drainage.6, m Percutaneous drainage is effective in about 70% of selected patients .3 Although a few reports show resolution of fungal abscesses with antifungal t h e r a p y alone, most require p r o m p t splenectomy and antifungal therapy.931,18
The authors gratefully acknowledge the efforts of I_inda Druelinger, MD; Karen Firster, RTR;and Pat Combo in the preparation of this manuscript. Address for reprints: Kevin B O'Dell, MD Department of EmergencyMedicine Gasten Memorial Hospital 2525 Court Drive Gastonia, North Carolina 28054
SUMMARY
A young adult with infectious mononucleosis, fever, and abdominal pain requiring emergency splenectomy is described. The emergency physician must be familiar with the underlying risk factors associated with splenic abscesses, as well as the life-threatening abdominal complications of infectious mononucleosis. REFERENCES 1. Churn CH, Raft MJ, Contreras L, et al: Splenic abscess. Medicine(Baltimore) 1980;59:50-65. 2. ReidSE, Lang SJ: Abscess of the spleen. Am J Surg 1954;98:912-917. 3. Nelken N, Ignatius J, Skinner M, et al: Changingclinical spectrum of splenic abscesses.A multicenter study and review of the literature. Am J Surg1987;154:27-34. 4. PicklemanJR, PaloyanE, Block GE:The surgical significance of splenic abscess. Surgery1970;68:287-290, 5, KrumbharrEB: Diseasesof the spleen, in 0gler W (ed): Modern Medicine, ed 3. Philadelphia,Lea & Febiger,1927,p 325-334. 6. Gleich S, Wolin DA, HerbsmanH: A review of percutaneous drainage in splenic abscess. $urg GynecolObstet1988;167:211-216.
7. ChulayJD, LankeraniMR: Splenic abscess. Report of 10 cases and review of the literature. Am J Med 1976;61:513-521. 8. GadaczT, Way LW, DunphyJE: Changing clinical spectrum of splenic abscess. Am J Surg1974;128:182-186. 9. HeltonWS, Carrico CJ, Zaveruha PA, et al: Diagnosisand treatment of splenic fungal abscessesin the immunosuppressedpatient. Arch Surg1988;121:580-588.
10. RobinsonRG:Abdominal complications of infectious mononucleosis.J Am Bd Faro Pract1988;1:207-210. 11. FraughtWE, GilbertsonJ J, Nelson EW: Splenic abscess: Presentation,treatment options,and results. Am J Surg 1989;158:612-614. 12.Teich S, Oliver GC, CanterJW: The early diagnosis of splenic abscess. Am Surg 1986;52:303-307. 13. Starr MG, FuidemaGD: Splenic abscess. Presentation,diagnosis and treatment. Surgery1982;92:480-485. 14. Stringel G, Anderson N, Martin D: Splenic abscess. CanJ Surg 1985;28:269-270. 15.Zatzkim HR, DrazanAD, InNin GA: Roentgenographicdiagnosis of splenic abscess. Am J RoentgenolRad TherNucl Med 1964;91:896-901. 16. Ferrucci JT, VanSonnenbergE: Intraabdominal abscess; radiological diagnosis and treatment, JAMA 1981;248:2728-2733. 17. Koehler PR, Moss AA: Diagnosisof intraabdominal and pelvic abscesses by computerizedtomography. JAMA 1980;244:49-52. 18. RamakrishnanMR, Sarathy TP, Balum NR: Percutaneousdrainage of splenic abscess: Casereport and review of literature. Pediatrics1987;79:1029-1031.
1 6 6 / 1 1 62
ERRATA In the editorial "Meeting the Needs of the Sexual Assauh Victim" [June 1992;21:741-742], the name of Peggy Goldman, MD, FACEP, was given incorrectly as Golden. In the article "Prehospital Pulse Oximetry: Useful or Misued?" [June 1992;21:675-679], the name of Howard Gershman, MD, PhD, was given incorrectly as Gersham.
ANNALS OF EMERGENCY MEDICINE 21:9 SEPTEMBER 1992
infectious mononucleosis; splenic abscess
RupturedSplenic Abscess Secondary to Infectious Mononucleosis
From the Department of Emergency Medicine, Gaston Memorial Hospital, Gastonia, North Carolina. Received for publication December 26, 1991. Revision received April 20, 1992. Accepted for publication May 8, 1992.
Kevin B O'Dell, MD Ronald S Gordon, MD
A 24-year-old woman with a recent diagnosis of infectious mononucleosis presented with fever and left upper quadrant pain. Abdominal computed tomography revealed a splenic abscess that at laparotomy was found to have ruptured. This case illustrates a rare cause of splenic abscess and a rare complication of infectious mononucleosis. [O'Dell KB, Gordon RS: Ruptured splenic abscess secondary to infectious mononucleosis. Ann EmergMed September 1992;21:1160-1162.] INTRODUCTION Splenic abscess is a r a r e entity with multiple etiologies. Fewer than 400 cases are described in the medical literature despite population-based autopsy studies that describe an incidence of 0.26% to 0.67%. 1-5 We present the r a r e association of infectious mononucleosis complicated by splenic abscess.
CASE
REPORT
A 24-year-old woman presented to the emergency d e p a r t m e n t with a three-day history of malaise, fever, and left upperq u a d r a n t pain. Two weeks earlier, she had had pharyngitis and right pleuritic chest pain. At that time, a positive heterophil agglutination resulted in the diagnosis of infectious mononucleosis. At the time of presentation, she denied nausea, vomiting, d i a r r h e a , fever, chills or hematochezia. She also denied IV drug abuse, ethanol abuse, or abdominal trauma. Physical examination revealed a thin woman in mild distress. Blood pressure was 110/68 mm Hg in both arms; pulse, 102; oral temperature, 36.8 C; and respirations, 18. Orthostatics were positive with a pulse rise of 30. The p h a r y n x , tympanic membranes, and sclera were u n r e m a r k a b l e . The neck was supple without lymphadenopathy. Cardiovascular examination revealed a regular tachycardic rate and r h y t h m without m u r m u r or gallop. The lungs were clear. Abdominal examination revealed moderate left u p p e r - q u a d r a n t tenderness without r e b o u n d , guarding, or distension. Bowel sounds were normoactive. The inferior pole of the spleen was palpable, and no a b n o r m a l pulsations were appreciated. The stool was guaiac negative. Gynecologic examination revealed no cervical motion tenderness or palpable masses. P e r i p h e r a l pulses were bounding and equal. The mental status and neurologic examinations were normal.
164/1160
ANNALS OF EMERGENCY MEDtCINE 21:9 SEPTEMBER1992
SPLENIC RUPTURE
O'DeU& Gordon
The chest and upright abdominal radiographs were normal. The ECG showed a sinus tachycardia without ischemia or prior infarction. Laboratory results included a hemoglobin of 11.5 g/dL; hematocrit, 34.6%; leukocyte count, 16,200/ram 3 with 35% neutrophils, 26% lymphocytes, and 35% bands; platelets, 400,000/ram3; serum sodium, 139 mEq/L; potassium, 3.7 mEq/L; chloride, 100 mEq/L; COx, 25 mEq/L; glucose, 100 mg/dL; blood urea nitrogen, 6 mg/dL; creatinine, 0.7 mg%; amylase, 37 dye units/dL; and a negative urine B-HCG. A repeat oral temperature was 40 C two hours later. Abdominal examination at that time revealed severe left upper-quadrant tenderness with voluntary guarding and rebound tenderness. Surgical consultation was obtained for a presumed diagnosis of splenic abscess or infected splenic hematoma. Blood and urine cultures were performed, and aggressive crystalloid hydration and IV cefuroxime were administered. The surgical consultant requested a computed tomography scan of the abdomen that revealed a low-density lesion measuring 4 × 5 cm in the lateral aspect of the spleen, as well as borderline splenomegaly (Figure). The splenic cyst was thought to be consistent with a congenital cyst, hematoma, or abscess. Emergency exploratory laparotomy showed an enlarged spleen with a 4-cm ruptured abscess that had adhered to the tail of the pancreas and transverse mesoeolon. A splcnectomy, hepatic needle biopsy, and abscess cultures were performed. Two Jackson-Pratt drains were placed, and vigorous intraperitoneal irrigation was performed. Pneumococeal polyvalent vaccine was also administered. Intraoperative cultures grew Fusobacterium nucleatum, which was treated with the IV regimen of ampicillin, gentamicin, and clindamycin postoperatively. Pathology revealed splenic red pulp infiltration by atypical lymphocytes and plasma cells as well as a mild mononuclear hepatitis, both consistent with Epstein-Barr viral infection. The patient's postoperative course was complicated by a severe pancreatitis requiring three weeks of central hyperalimentation. A left subphrenic abscess developed and required percutaneous drainage ten days after splenectomy. The patient was discharged on postoperative day 31 tolerating clear liquids.
oxygen delivery, predisposing to abscess formation, a Immunodeficiency causes include immunosuppressiye drugs, diabetes mellitus, IV drug abuse, and AIDS. 1,3,9 Splenic abscess associated with infectious mononucleosis has been reported previously in a single case report. 7 Abdominal complications of infectious mononucleosis include splenic rupture, hepatitis, mesenteric adenitis, pancreatitis, and transient malabsorption, lO Left lower-lobe pneumonia secondary to Epstein-Barr virus infection also may produce abdominal complaints. The clinical presentation of splenic abscess is often subtle, with pain being the most frequent symptom. 11 The pain, usually pleuritic, may be in the left flank, left chest, left upper and lower abdomen, or left shoulder. Left upperquadrant tenderness is seen in 40% and splenomegaly in 50% of patients.l,11,12 Fever and leukocytosis is seen in up to 80% of patients, with positive blood cultures in 50% to 60%. 1,13 Organisms cultured from splenic abscesses include Staphylococcus aureus, Streptococcus moniliformis, and Gram-negative bacilli, most commonly Escherichia coli. 1,8,13,14 Mycobacteria and fungal infection are increasingly seen, with a 25% fungal etiology in one recent review. 9 Plain abdominal radiographs may show a left upperquadrant mass effect or extra-alimentary gas. Plain chest radiographs show left hemidiaphragm elevation with or without a pleural effusion in up to 80%.13,15 Ultrasound, gallium, indium, and liver-spleen scans have been used previously to detect splenic abscesses, but computed tomography has demonstrated a sensitivity and specificity rate of 90% to 95%. 16,17 In a recent series, the use of computed tomography for earlier diagnosis and aggressive antibiotic therapy decreased mortality to 10%. 7 Splenectomy remains the procedure of choice for bacterial splenic abscesses. Select patients may be managed with computed tomography-gnided percutaneous drainage, especially Figure.
Computed tomography scan showing splenic abscess
DISCUSSION
Splenic abscess remains a rare entity with mortality rates as high as 40%, despite appropriate antibiotic therapy. 3 The causes of splenic abscesses may be grouped into five categories: contiguous infection, metastatic infection (embolic infectious), embolic noninfectious events, trauma, and immunodeficiency. 1,3,6 Of the embolic infectious variety, bacterial endocarditis is the most common focus. Abscess formation after trauma may be seen weeks or months later. 7 Embolic noninfectious causes such as hemoglobinopathies and hematologic malignancies decrease splenic perfusion and
SEPTEMBER 1992
21:9
ANNALS OF EMERGENCY MEDICINE
1 1 6 1/ 1 6 5
SPLENIC RUPTURE O'DeU & Gordon
those with unilocular abscesses with weU-deFmed walls and nonseptated fluid collections. Suspected abscess r u p t u r e , multiple or muhilocular abscesses, p e r i h i l a r abscesses, a n d bleeding diatheses are relative contraindications to percutaneous drainage.6, m Percutaneous drainage is effective in about 70% of selected patients .3 Although a few reports show resolution of fungal abscesses with antifungal t h e r a p y alone, most require p r o m p t splenectomy and antifungal therapy.931,18
The authors gratefully acknowledge the efforts of I_inda Druelinger, MD; Karen Firster, RTR;and Pat Combo in the preparation of this manuscript. Address for reprints: Kevin B O'Dell, MD Department of EmergencyMedicine Gasten Memorial Hospital 2525 Court Drive Gastonia, North Carolina 28054
SUMMARY
A young adult with infectious mononucleosis, fever, and abdominal pain requiring emergency splenectomy is described. The emergency physician must be familiar with the underlying risk factors associated with splenic abscesses, as well as the life-threatening abdominal complications of infectious mononucleosis. REFERENCES 1. Churn CH, Raft MJ, Contreras L, et al: Splenic abscess. Medicine(Baltimore) 1980;59:50-65. 2. ReidSE, Lang SJ: Abscess of the spleen. Am J Surg 1954;98:912-917. 3. Nelken N, Ignatius J, Skinner M, et al: Changingclinical spectrum of splenic abscesses.A multicenter study and review of the literature. Am J Surg1987;154:27-34. 4. PicklemanJR, PaloyanE, Block GE:The surgical significance of splenic abscess. Surgery1970;68:287-290, 5, KrumbharrEB: Diseasesof the spleen, in 0gler W (ed): Modern Medicine, ed 3. Philadelphia,Lea & Febiger,1927,p 325-334. 6. Gleich S, Wolin DA, HerbsmanH: A review of percutaneous drainage in splenic abscess. $urg GynecolObstet1988;167:211-216.
7. ChulayJD, LankeraniMR: Splenic abscess. Report of 10 cases and review of the literature. Am J Med 1976;61:513-521. 8. GadaczT, Way LW, DunphyJE: Changing clinical spectrum of splenic abscess. Am J Surg1974;128:182-186. 9. HeltonWS, Carrico CJ, Zaveruha PA, et al: Diagnosisand treatment of splenic fungal abscessesin the immunosuppressedpatient. Arch Surg1988;121:580-588.
10. RobinsonRG:Abdominal complications of infectious mononucleosis.J Am Bd Faro Pract1988;1:207-210. 11. FraughtWE, GilbertsonJ J, Nelson EW: Splenic abscess: Presentation,treatment options,and results. Am J Surg 1989;158:612-614. 12.Teich S, Oliver GC, CanterJW: The early diagnosis of splenic abscess. Am Surg 1986;52:303-307. 13. Starr MG, FuidemaGD: Splenic abscess. Presentation,diagnosis and treatment. Surgery1982;92:480-485. 14. Stringel G, Anderson N, Martin D: Splenic abscess. CanJ Surg 1985;28:269-270. 15.Zatzkim HR, DrazanAD, InNin GA: Roentgenographicdiagnosis of splenic abscess. Am J RoentgenolRad TherNucl Med 1964;91:896-901. 16. Ferrucci JT, VanSonnenbergE: Intraabdominal abscess; radiological diagnosis and treatment, JAMA 1981;248:2728-2733. 17. Koehler PR, Moss AA: Diagnosisof intraabdominal and pelvic abscesses by computerizedtomography. JAMA 1980;244:49-52. 18. RamakrishnanMR, Sarathy TP, Balum NR: Percutaneousdrainage of splenic abscess: Casereport and review of literature. Pediatrics1987;79:1029-1031.
1 6 6 / 1 1 62
ERRATA In the editorial "Meeting the Needs of the Sexual Assauh Victim" [June 1992;21:741-742], the name of Peggy Goldman, MD, FACEP, was given incorrectly as Golden. In the article "Prehospital Pulse Oximetry: Useful or Misued?" [June 1992;21:675-679], the name of Howard Gershman, MD, PhD, was given incorrectly as Gersham.
ANNALS OF EMERGENCY MEDICINE 21:9 SEPTEMBER 1992
