nonsurgical management of complicated sp”>Case Report

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American Journal of Emergency Medicine

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Nonsurgical management of complicated splenic rupture in Infectious mononucleosis

Abstract

We report on a 35-year-old man who presented to the emergency department with acute abdominal pain, postural hypotension, and tachycardia after having been diagnosed with Epstein-Barr virus infection 1 week before. Abdominal ultrasound and computed tomography revealed splenic rupture, and the patient underwent successful proximal angiographic embolization of the splenic artery. The course was complicated by painful splenic necrosis and respiratory insufficiency due to bilateral pleural effusions. Six weeks later, he additionally developed severe sepsis with Propionibacterium granulosum due to an intrasplenic infected hematoma, which required drainage. All complications were treated without surgical splenectomy, and the patient finally made a Full recovery.

A previously healthy 35-year-old man presented to the emergency department with acute abdominal pain, postural hypotension, and tachycardia. Symptoms started after heavy coughing, which followed a 1-week history of fever, sore throat, cervical lymphadenopathy, and fatigue, for which he was tested positive for infectious mononucleosis. On initial examination, the patient had a heart rate of 94 per minute and an arterial blood pressure of 124/62 mm Hg. Lactate was 1.2 mmol/L, and hemoglobin level was 109 g/L. After demonstration of free abdominal fluids in the ultrasound, he underwent a contrast- enhanced computed tomography showing a rupture of the spleen with laceration in the splenic convexity of 15 mm, correspondent to grade 3 according to the classification of the American Association for the Surgery of Trauma (Fig. 1). Furthermore, there was subcapsular and intra-abdominal hematoma with approximately 700 mL of free fluids. The patient was admitted to the intensive care unit for resuscitation and Close monitoring. Because of a drop of Hb level to 86 g/L, the patient was transferred to a tertiary care center for embolization of the splenic artery (Fig. 2). After proximal angioembolization, the patient’s condition improved, and Hb levels increased, so that he could be discharged to the regular unit 2 days later. However, recurrent abdominal pain and fever occurred the next day. An abdominal computed tomographic scan was performed (Fig. 3) and showed inclusions of gas in the splenic infarction area. Splenic perfusion at that time had decreased from 75% to 30% in contrast agent sonography. Subsequently, the patient developed respiratory insufficiency (partial pressure of oxygen, 7.8 kPa; PCO2, 5.5 kPa) due to bilateral pleural effusions. Right-sided therapeutic thor- acentesis revealed hemorrhagic exudates (1700 mL). Three weeks after hospital discharge, the patient developed severe sepsis with Propionibacterium granulosum due to an intrasplenic infected

hematoma with a volume of 1500 mL. The patient recovered after ultrasound-guided transcutaneous drainage with a Pigtail catheter and intravenous therapy with amoxicillin/clavulanic acid. Eleven days later, he was discharged from the hospital, and the Pigtail drainage was removed on day 15, whereas the abscess volume had diminished to 200 mL. On a follow-up 3 months later, the patient had made a full recovery and was back at work.

Epstein-Barr virus (EBV) infection is a common infection during adolescence, and approximately 90% of adults are EBV seropositive. Clinically relevant splenomegaly develops in up to 50% of patients with acute EBV infection [1]. Because of splenic infiltration with lymphocytes and atypical lymphoid cells, the splenic capsule is thinned out, and traumatic or atraumatic splenic rupture, as Life-threatening complication, may occur. Atraumatic splenic rupture is described in 0.1% to 0.5% of patients with EBV infection [1] mostly between the 7th and 28th day of illness [1]. Atraumatic splenic rupture might occur as a consequence of increased venous pressure during Valsalva manoeuvres such as coughing [1]. Until recently, the standard therapeutic approach was operative splenectomy. However, in recent years, several case reports have described successful Nonoperative management of Spontaneous splenic rupture [2], including the first report of a successful angioembolization in spontaneous splenic rupture in infectious mononucleosis [3]. In traumatic splenic injury, the current standard of care has changed from surgical exploration to a nonoperative management in patients who are hemodynamically stable. In this setting, transcatheter Splenic artery embolization has a success rate of 73% to 100% [4]. Proximal splenic artery embolization is thought to reduce splenic artery pressure, which facilitates clot formation and, consequently, the healing of the spleen. Rapidly after embolization, a collateral arterial network develops to maintain splenic perfusion. The Western Trauma Association multi-institutional trial [5] described complications of splenic artery embolization in 20% of patients, whereas bleeding is the most common complication accounting for 11% of all complications. Half of these patients required secondary surgical splenectomy. In other cases, repeated splenic embolization could even increase the overall success rate of nonoperative manage- ment. Other complications include significant infarction (21% of all patients), which are more frequent in distal than proximal embolization (27% vs 19%). These infarct areas might include gas and cause fever, as described in our patient. Abscess formation (3% of all patients), coil migration and incidental infarction of other organs, allergic contrast reactions, puncture site hematomas, and pleural effusions are other rare complications.

This case report describes a patient with several complications

after splenic rupture, which were all successfully managed without surgical splenectomy. Splenic angioembolization is a

0735-6757/$ – see front matter (C) 2013

Fig. 1. Computed tomography at admission shows splenic rupture American Association for the Surgery of Trauma grade 3.

Fig. 2. Angiogram after splenic angioembolization.

valuable alternative to surgery in atraumatic splenic rupture. Future studies are needed to study the splenic function after such procedures.

Acknowledgments

We thank PD Dr A. Rudiger for his critical reading of this report, and Dr E. Schoch for providing the image of the angiogram.

Fabienne Jenni MD

Clinic for Internal Medicine, Buelach Hospital

CH 8180 Buelach, Switzerland E-mail address: [email protected]

Fig. 3. Gas inclusions in splenic infarction area.

Barbara Lienhardt MD

Interdisciplinary Intensive Care Unit, Buelach Hospital

CH 8180 Buelach, Switzerland

Gabriela Fahrni MD Clinic for Surgery, Buelach Hospital CH 8180 Buelach, Switzerland

Bernd Yuen MD

Interdisciplinary Intensive Care Unit, Buelach Hospital

CH 8180 Buelach, Switzerland

http://dx.doi.org/10.1016/j.ajem.2013.02.033

References

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