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Possible infectious causes of spontaneous splenic rupture: a case report.

Lam GY, Chan AK, Powis JE - J Med Case Rep (2014)

Bottom Line: Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein-Barr virus reinfection are reviewed.

View Article: PubMed Central - PubMed

Affiliation: Department of Infectious Diseases, Toronto East General Hospital, 825 Coxwell Ave, Toronto, ON, M4C 3E7, Canada. jpowi@tegh.on.ca.

ABSTRACT

Introduction: Spontaneous atraumatic splenic rupture is a rare but dramatic occurrence that is most commonly attributed to infection or neoplasia. Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.

Case presentation: We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.

Conclusions: The differential diagnosis for atraumatic splenic rupture, specifically its infectious causes, is reviewed. Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein-Barr virus reinfection are reviewed.

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Related in: MedlinePlus

Computed tomography images of atraumatic splenic rupture. Representative sagittal (left) and axial (right) computed tomography images of the patient’s abdomen taken on the day she presented to the hospital. Grade 3 splenic injury (crescent-shaped subcapsular hematoma measuring up to 3cm in thickness along the lateral border of the spleen with lobulated regions of hemorrhage along the superior and medial border of the spleen and left subdiaphragmatic region, and linear densities in the spleen) and marked splenomegaly can be seen.
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Fig1: Computed tomography images of atraumatic splenic rupture. Representative sagittal (left) and axial (right) computed tomography images of the patient’s abdomen taken on the day she presented to the hospital. Grade 3 splenic injury (crescent-shaped subcapsular hematoma measuring up to 3cm in thickness along the lateral border of the spleen with lobulated regions of hemorrhage along the superior and medial border of the spleen and left subdiaphragmatic region, and linear densities in the spleen) and marked splenomegaly can be seen.

Mentions: While in the emergency department, she was found to be alert and orientated but in significant pain. She was afebrile, heart rate of 94 beats per minute and blood pressure of 98/45mmHg. She did not have any rashes or dermatological findings. No lymphadenopathy was found but significant abdominal discomfort on light palpation and hepatosplenomegaly were noted. No rigidity or guarding or peritoneal signs were elicited. There was no rebound tenderness. CT imaging showed hepatosplenomegaly (liver span: 19.4cm; spleen length: 14.5cm) with subcapsular hematoma in the spleen and hematoma in the left subphrenic perisplenic regions, consistent with grade III splenic rupture with associated mild abdominal and pelvic ascites (Figure 1). Her liver enzymes were as follows: aspartate aminotransferase 146U/L, alkaline phosphatase 67U/L, alanine aminotransferase 166U/L and total bilirubin 6.0μmol/L. Her hemoglobin was 102g/L, white blood cells 6.8 × 109 cells/L and platelets of 131 × 109 cells/L. A blood smear showed no atypical lymphocytes and the differential was otherwise normal. The rest of her routine biochemical investigations were unremarkable. She received immediate hemodynamic stabilization in the ICU and was followed closely by General Surgery. During this time, she received a full infectious diseases workup. She had negative blood cultures and negative serologies for viral hepatitis, human immunodeficiency virus, cytomegalovirus, parvovirus, toxoplasmosis, and syphilis. She had negative Legionella urinary antigen. Her Monospot test was negative, but Epstein–Barr virus (EBV) serology showed EBV viral-capsid antigen (VCA) immunoglobulin (Ig) G reactivity and early antigen (EA) IgG reactivity but Epstein–Barr virus nuclear antigen (EBNA) IgG and EBV VCA IgM non-reactivity. Finally her Bartonella serology showed IgG reactivity (titers 1:128). Her transthoracic echocardiogram was negative for signs of bacterial endocarditis. She remained hemodynamically stable in the ICU and was discharged without need for any surgical interventions. One week after discharge, she returned to the Infectious Disease clinic with ongoing complaints of fatigue and improving abdominal pain. She was started on a 2-week course of azithromycin and rifampin and improved symptomatically (decreased pain and improved energy) and biochemically (normalization of her liver enzymes) over a 2-week period. She was seen back in follow up 3 months later. She remained well clinically with normal liver enzymes. Repeat Bartonella serological titers remained at 1:128 with conversion of EBNA IgG to reactive.Figure 1


Possible infectious causes of spontaneous splenic rupture: a case report.

Lam GY, Chan AK, Powis JE - J Med Case Rep (2014)

Computed tomography images of atraumatic splenic rupture. Representative sagittal (left) and axial (right) computed tomography images of the patient’s abdomen taken on the day she presented to the hospital. Grade 3 splenic injury (crescent-shaped subcapsular hematoma measuring up to 3cm in thickness along the lateral border of the spleen with lobulated regions of hemorrhage along the superior and medial border of the spleen and left subdiaphragmatic region, and linear densities in the spleen) and marked splenomegaly can be seen.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4289345&req=5

Fig1: Computed tomography images of atraumatic splenic rupture. Representative sagittal (left) and axial (right) computed tomography images of the patient’s abdomen taken on the day she presented to the hospital. Grade 3 splenic injury (crescent-shaped subcapsular hematoma measuring up to 3cm in thickness along the lateral border of the spleen with lobulated regions of hemorrhage along the superior and medial border of the spleen and left subdiaphragmatic region, and linear densities in the spleen) and marked splenomegaly can be seen.
Mentions: While in the emergency department, she was found to be alert and orientated but in significant pain. She was afebrile, heart rate of 94 beats per minute and blood pressure of 98/45mmHg. She did not have any rashes or dermatological findings. No lymphadenopathy was found but significant abdominal discomfort on light palpation and hepatosplenomegaly were noted. No rigidity or guarding or peritoneal signs were elicited. There was no rebound tenderness. CT imaging showed hepatosplenomegaly (liver span: 19.4cm; spleen length: 14.5cm) with subcapsular hematoma in the spleen and hematoma in the left subphrenic perisplenic regions, consistent with grade III splenic rupture with associated mild abdominal and pelvic ascites (Figure 1). Her liver enzymes were as follows: aspartate aminotransferase 146U/L, alkaline phosphatase 67U/L, alanine aminotransferase 166U/L and total bilirubin 6.0μmol/L. Her hemoglobin was 102g/L, white blood cells 6.8 × 109 cells/L and platelets of 131 × 109 cells/L. A blood smear showed no atypical lymphocytes and the differential was otherwise normal. The rest of her routine biochemical investigations were unremarkable. She received immediate hemodynamic stabilization in the ICU and was followed closely by General Surgery. During this time, she received a full infectious diseases workup. She had negative blood cultures and negative serologies for viral hepatitis, human immunodeficiency virus, cytomegalovirus, parvovirus, toxoplasmosis, and syphilis. She had negative Legionella urinary antigen. Her Monospot test was negative, but Epstein–Barr virus (EBV) serology showed EBV viral-capsid antigen (VCA) immunoglobulin (Ig) G reactivity and early antigen (EA) IgG reactivity but Epstein–Barr virus nuclear antigen (EBNA) IgG and EBV VCA IgM non-reactivity. Finally her Bartonella serology showed IgG reactivity (titers 1:128). Her transthoracic echocardiogram was negative for signs of bacterial endocarditis. She remained hemodynamically stable in the ICU and was discharged without need for any surgical interventions. One week after discharge, she returned to the Infectious Disease clinic with ongoing complaints of fatigue and improving abdominal pain. She was started on a 2-week course of azithromycin and rifampin and improved symptomatically (decreased pain and improved energy) and biochemically (normalization of her liver enzymes) over a 2-week period. She was seen back in follow up 3 months later. She remained well clinically with normal liver enzymes. Repeat Bartonella serological titers remained at 1:128 with conversion of EBNA IgG to reactive.Figure 1

Bottom Line: Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein-Barr virus reinfection are reviewed.

View Article: PubMed Central - PubMed

Affiliation: Department of Infectious Diseases, Toronto East General Hospital, 825 Coxwell Ave, Toronto, ON, M4C 3E7, Canada. jpowi@tegh.on.ca.

ABSTRACT

Introduction: Spontaneous atraumatic splenic rupture is a rare but dramatic occurrence that is most commonly attributed to infection or neoplasia. Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.

Case presentation: We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.

Conclusions: The differential diagnosis for atraumatic splenic rupture, specifically its infectious causes, is reviewed. Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein-Barr virus reinfection are reviewed.

Show MeSH
Related in: MedlinePlus