Splenic rupture in infectious mononucleosis: A systematic review of published case reports

Liver Function Test Results Correlate With Spleen Size in Patients With Infectious Mononucleosis

INTRODUCTION

We aimed to evaluate the efficacy of measuring transaminase levels to determine the resolution of splenomegaly in athletes diagnosed with infectious mononucleosis (IM).

METHODS

We collected serial aspartate aminotransferase (AST) and alanine transaminase (ALT) levels and ultrasound-measured spleen sizes in university athletes who had been diagnosed with IM. Our study included seven university-aged athletes from a single institution. Patients received serial liver function tests (LFT) and splenic ultrasound testing until resolution of symptoms and full return to sport. The effects of AST, ALT, and days from symptom onset were analyzed using multivariable mixed-effects linear regression models.

RESULTS

Levels of AST and ALT were significantly correlated with spleen size. For each 10-unit increase in AST and ALT values, spleen size increased by 0.1 cm (p = 0.007) and 0.09 cm (p = 0.008), respectively. Decreasing levels of ALT and AST correlated with a decrease in spleen size. Normalization of AST/ALT values correlated with return of spleen size to baseline.

CONCLUSIONS

Liver function testing may be useful in the return-to-play decision-making process for athletes with IM.

Atypical presentation of spontaneous splenic rupture secondary to Epstein-Barr virus infection

We present a case of atraumatic splenic rupture secondary to Epstein-Barr virus (EBV) infection in a woman in her early 50s. The patient initially presented with sepsis secondary to pneumonia but then developed abdominal pain and distension. CT revealed splenic rupture with a significant perisplenic hematoma. Laboratory tests confirmed an EBV infection. Owing to frailty, she underwent fluoroscopy-guided splenic artery embolisation. This case highlights the rare risk of splenic rupture following EBV infection, even in the absence of typical symptoms of infectious mononucleosis.

A rare case report of splenic infarction in a previously healthy teenager caused by acute infectious mononucleosis

RATIONALE

Splenic infarction usually occurs in patients with underlying illnesses such as thromboembolic disorders and infiltrative hematologic diseases. Herein, we report a rare case of splenic infarction in a previously healthy boy diagnosed with infectious mononucleosis (IM). Splenic infarction is a rare complication of IM and its incidence is unknown. This case report summarizes the clinical characteristics, treatment options, and anticipated time for recovery from splenic infarction in IM.

PATIENT CONCERN

A16-year-old boy presented to our clinic with complaints of fever, sore throat, and general sweakness for 7 days. The patient was diagnosed with IM due to an Epstein-Barr virus infection. Two days later, the patient developed severe abdominal pain in the left upper quadrant and returned to our ER for further evaluation.

DIAGNOSIS

IM complicated with splenic infarction.

INTERVENTIONS

Contrast-enhanced CT confirmed the diagnosis of splenic infarction. This patient was admitted for supportive treatment and close medical monitoring. Surgical.

OUTCOMES

The patient recovered well with conservative treatment.

LESSONS

IM is most often seen in adolescents and young adults. Splenic infarction is a rare complication of IM, particularly in patients who do not usually have any underlying predisposing medical conditions. Contrast-enhanced CT is the imaging modality of choice in suspected cases. Early recognition and treatment of splenic infarction in patients with IM can help prevent potentially life-threatening events. Patients should be advised to avoid sports that may precipitate splenic rupture. However it is still unknown when it is safe for patients to resume sports. In our case, 6 weeks after the splenic infarction, the patient generally felt well with complete resolution of objective symptoms and splenomegaly, and resumed sports without experiencing any adverse events.

A Real Gut Punch: An Unexpected Diagnosis of Spontaneous Splenic Rupture

Atraumatic or spontaneous splenic rupture is a rare but life-threatening complication of infectious mononucleosis. We present a case of a 26-year-old man presenting with a 1-week history of sharp epigastric and right upper quadrant pain, associated with malaise and subjective fever. Although initial findings were concerning for acute cholangitis, abdominal computed tomography angiography scan revealed splenic rupture. Further exploration confirmed acute Epstein-Barr virus infection. Infectious mononucleosis must be considered in young patients with lymphocytosis, splenomegaly, and prolonged malaise. Awareness of this presentation will allow for timely diagnosis and treatment, thereby preventing potentially fatal complications of infectious mononucleosis such as splenic rupture.

A case report of successful splenic artery embolization for atraumatic splenic rupture secondary to Epstein Barr virus infection in a haemodynamically unstable patient

Splenic rupture in haemodynamically unstable patients has traditionally been managed with splenectomy. This case report discusses the successful management of atraumatic splenic rupture, a rare but life-threatening complication of Epstein-Barr virus (EBV) infection, in a hemodynamically unstable patient. The patient, diagnosed with infectious mononucleosis (IM) secondary to EBV, presented with severe abdominal pain and a syncopal episode. Imaging revealed an American Association for the Surgery of Trauma (AAST) grade III splenic injury, which was subsequently upgraded to a grade IV injury on repeat imaging. The patient's condition deteriorated even with initial resuscitation, leading to splenic angioembolization. The procedure was successful and the patient was discharged after 5 days. This case highlights the efficacy of splenic artery embolization (SAE) in haemodynamically unstable patients with atraumatic splenic rupture, particularly in centers with interventional radiology resources, offering an alternative to splenectomy and its associated complications.

Spontaneous splenic rupture associated with scrub typhus: a case report

BACKGROUND

Scrub typhus, an acute febrile disease with mild to severe, life-threatening manifestations, potentially presents with a variety of complications, including pneumonia, acute respiratory distress syndrome, cardiac arrhythmias (such as atrial fibrillation), myocarditis, shock, peptic ulcer, gastrointestinal bleeding, meningitis, encephalitis, and renal failure. Of the various complications associated with scrub typhus, splenic rupture has rarely been reported, and its mechanisms are unknown. This study reports a case of scrub typhus-related spontaneous splenic rupture and identifies possible mechanisms through the gross and histopathologic findings.

CASE PRESENTATION

A 78-year-old man presented to our emergency room with a 5-day history of fever and skin rash. On physical examination, eschar was observed on the left upper abdominal quadrant. The abdomen was not tender, and there was no history of trauma. The Orientia tsutsugamushi antibody titer using the indirect immunofluorescent antibody test was 1:640. On Day 6 of hospitalization, he complained of sudden-onset left upper abdominal quadrant pain and showed mental changes. His vital signs were a blood pressure of 70/40 mmHg, a heart rate pf 140 beats per min, and a respiratory rate of 20 breaths per min, with a temperature of 36.8 °C. There were no signs of gastrointestinal bleeding, such as hematemesis, melena, or hematochezia. Grey Turner's sign was suspected during an abdominal examination. Portable ultrasonography showed retroperitoneal bleeding, so an emergency exploratory laparotomy was performed, leading to a diagnosis of hemoperitoneum due to splenic rupture and a splenectomy. The patient had been taking oral doxycycline (100 mg twice daily) for 6 days; after surgery, this was discontinued, and intravenous azithromycin (500 mg daily) was administered. No arrhythmia associated with azithromycin was observed. However, renal failure with hemodialysis, persistent hyperbilirubinemia, and multiorgan failure occurred. The patient did not recover and died on the fifty-sixth day of hospitalization.

CONCLUSIONS

Clinicians should consider the possibility of splenic rupture in patients with scrub typhus who display sudden-onset abdominal pain and unstable vital signs. In addition, splenic capsular rupture and extra-capsular hemorrhage are thought to be caused by splenomegaly and capsular distention resulting from red blood cell congestion in the red pulp destroying the splenic sinus.

Unexpected death involving the spleen - an overview

The spleen is located in the left upper quadrant of the abdominal cavity and has both immunological and haematological functions. A variety of quite different entities may be associated with sudden death due to splenic involvement. These range from simple traumatic disruption of the parenchyma of a normal spleen with marked intra-abdominal haemorrhage, to conditions such as malaria and infectious mononucleosis where splenomegaly predisposes to rupture. Haematological diseases such as malignancies and haemoglobinopathies may causes sudden death due to haemorrhage or red cell sequestration. Asplenia or polysplenia may be associated with significant congenital heart disease. Hyposplenia, both structural and functional, may also result in rapid demise from sometimes unusual bacterial infections. Vascular abnormalities causing death include entities such as splenic artery aneurysms. Thus, deaths from splenic pathology may be due to localised issues or may be part of more generalised disease. For this reason the autopsy in cases of splenic-associated deaths must be comprehensive and include special testing such as microbiological screening and/or haematologic/genetic evaluation.

Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023-Part 1. Pre-participation physical evaluation in young athletes

The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.

American Medical Society of Sports Medicine Position Statement: Mononucleosis and Athletic Participation

ABSTRACT

Infectious mononucleosis (IM) is a common illness in children and young adults caused primarily by the Epstein-Barr Virus (EBV). Transmission occurs primarily through sharing oral secretions, thus IM is known as the "kissing disease." Common clinical manifestations include fever, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Atypical lymphocytosis and transaminase elevations are common, and the diagnosis of IM is confirmed with laboratory findings of a positive heterophile antibody ("Monospot"), polymerase chain reaction, or antibodies specific to EBV. Individuals with acute IM may be quite symptomatic and not feel well enough to participate in sports. Splenic enlargement is common, with rupture a relatively rare occurrence, typically occurring within a month of symptom onset, but this risk complicates sports participation, and is often the reason for restricting activity. The management of IM is primarily supportive, with no role for antivirals or corticosteroids. The variability of clinical presentation and the risk of splenic rupture in patients with IM present clinicians with challenging return to play/return to sport (RTS) decisions. This position statement updates the Evidence-Based Subject Review on Mononucleosis by the American Medical Society for Sports Medicine published in 2008 and reviews the epidemiology, clinical manifestations, laboratory assessment, and management including RTS for the athlete with IM. This statement also addresses complications, imaging, special considerations, diversity and equity considerations, and areas for future clinical research. Understanding the evidence regarding IM and sport is essential when communicating with athletes and their families and incorporating shared decision-making in the RTS decision.

A case of infectious mononucleosis complicated with spontaneous atraumatic splenic rapture caused by Epstein-Barr virus infection

Splenic rupture is the most serious complication of infectious mononucleosis (IM) caused by Epstein-Barr virus (EBV) infection, with a mortality rate of over 1 in 10. We reported a case of spontaneous atraumatic splenic rupture secondary to IM in a young man. The patient presented with abdominal pain caused by splenic rupture as the initial symptom. The diagnosis and treatment process went through a series of twists and turns, including the emergency department, general surgery department, and infection department. This case suggests that clinicians should consider the possibility of EBV infection in young patients with spleen rupture without obvious cause to avoid misdiagnosis and missed diagnosis.

Red flags useful to screen for gastrointestinal and hepatic diseases in patients with shoulder pain: A scoping review

INTRODUCTION

In most patients, shoulder pain has a neuromusculoskeletal cause. However, it might conceal other types of disorders, hiding a non-neuromusculoskeletal condition. The main aim of this scoping review is to map and summarise findings to identify red flags for gastrointestinal and hepatic diseases in the assessment of patients with shoulder pain.

METHODS

Five databases were searched up to 31 May 2021. Additional studies have been identified through grey literature, and the reference lists of the included studies have been screened. Any study design and publication type have been considered to be eligible for inclusion. No time, geographical setting and language restrictions have been applied.

RESULTS

A total of 157 records have been identified, with 40 studies meeting the inclusion criteria (37 case reports, 2 retrospective studies and 1 systematic review with meta-analysis). The most prevalent red flags associated with shoulder pain were abdominal pain (14 cases) and abdominal discomfort (3 cases), reported by 47% of patients. As for comorbidities, hepato-gastric, cardiac, visceral and systemic diseases were the most common ones.

CONCLUSION

Abdominal pain, right and left hypochondriac pain, and epigastric pain represent the most prevalent symptoms in patients with an abdominal disease that could mimic a shoulder problem. Clinicians should be encouraged to screen for red flags when assessing patients with shoulder pain.

[Virus-induced exanthems in returning travellers]

Dermatological diseases are among the most common travel-associated diseases. In particular, viral infections not only with tropical and subtropical pathogens, but also with viruses common in Germany, which are often accompanied by skin rashes and general symptoms, are of great importance. In addition to an accurate travel history and possible risk exposures, epidemiological information on country-specific risks in combination with molecular and serological analyses is helpful in making the correct diagnosis. This article provides an overview of important virus-induced exanthems in returned travellers.

Splenic infarction diagnosed by contrast-enhanced ultrasound in infectious mononucleosis – An appropriate diagnostic option: A case report with review of the literature

Infectious mononucleosis is caused by Epstein.Barr virus (EBV) infection. Although typically self.limiting, complications such as splenic infarction and splenic rupture are described. A 17.year.old man presented in the emergency department due to a 3 days history of fever with chills, soreness, fatigue, and loose stool. Ultrasound examination showed a homoechogenic splenomegaly. Viral enteritis was diagnosed and the patient was dismissed. Six days later, he reassessed due to increasing left upper quadrant abdominal pain. Ultrasound showed inhomogeneous splenomegaly with irregular hypoechogenic subcapsular lesions. Contrast.enhanced ultrasound (CEUS) characterized the lesions as not perfused tissue until the late venous phase, compatible with spleen infarctions. Serologic studies were positive for EBV. In the literature, splenic infarction is considered under.recognized. Contrast.enhanced computed tomography (CECT) and magnetic resonance imaging are associated with costs and radiation (CECT). B.mode ultrasound examination is usually used as the first imaging modality, although showing a poor sensitivity in the question of splenic lesions/infarctions. CEUS has shown instead very good sensitivity and does not harm. Therefore, we recommend CEUS examination as the first imaging modality if suspicion of spleen infarction arises, especially when B.mode ultrasound is normal.

Analysis of two laboratory tests for determination of EBV-IM in children

This study aimed to explore the application value of two laboratory tests in the diagnosis of Epstein-Barr virus-associated infectious mononucleosis (EBV-IM) in children. From January 2018 to December 2020, 166 patients with EBV-IM were included in this study. Two methods were used in the analysis. The results of both tests were compared and analyzed. The age of onset of EBV-IM is mainly distributed in the range of 0-6 years, and no difference by gender is observed. The sensitivity and specificity of EBV testing by PCR were 49.4% and 89.8%, respectively, and the area under the receiver operating characteristic curve (AUC) was 0.714 (0.662-0.762). When using the immunofluorescence method to detect EBV antibodies, the two indices with the highest diagnostic efficacy were low-affinity EBV-CA IgG and EBV-CA IgM, and their AUC values were 0.798 (0.751-0.840) and 0.663 (0.609-0.713), respectively. When combining the two indices for testing, the AUC values of EBV-CA IgM + low-affinity EBV-CA IgG, EBV-DNA+EBV-CA IgM, and EBV-DNA+low-affinity EBV-CA IgG were 0.904 (0.867-0.933), 0.768 (0.719-0.812), and 0.963 (0.937-0.981), respectively. The diagnostic efficacy of the combined EBV-DNA+EBV-CA IgM + low-affinity EBV-CA IgG test was optimal compared with that of a single index or the combination of two indices, with an AUC of 0.999 (0.986-1.000; p < 0.05), sensitivity of 100%, and specificity of 89.8%. The combined immunofluorescence and real-time PCR methods have high sensitivity and specificity and good application value in the clinical diagnosis of EBV-IM.

Occult Abdominal Trauma

Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.

[Infectious mononucleosis in practice of otorhinolaryngologist]

Infectious mononucleosis (IM) is an acute viral infection that usually occurs with fever, acute tonsillitis, affects lymph nodes, liver, spleen, and with specific changes in the hemogram. One of the most frequent symptoms of the disease is sore throat which leads people to otorhinolaryngologist. Several pathogens may be the cause of IM, but Epstein-Barr virus(EBV) plays a key role. EBV is a γ-herpes virus and about 90% of world`s population is infected with this one. Severe IM can lead to potential life-threating conditions, for example upper airway obstruction, spleen rupture. In addition to acute IM, EBV-infection can lead to a number of neoplastic and autoimmune diseases. Due to the non-specificity of IM symptoms and the emerging difficulties in laboratory and serological diagnosis of this disease, the problem of timely diagnosis and treatment in this category of patients remains very relevant.

Infectious Mononucleosis: diagnosis and clinical interpretation

EBV is the sole causative agent of the acute illness in humans described either as infectious mononucleosis (IM), or glandular fever. IM, when not clinically silent, can present in patients with at least two of the classic triad of symptoms of fever, pharyngitis, and lymphadenopathy. Challenges for the clinician arise when atypical cases present. Early, accurate and informed laboratory test results are vital for diagnosis, appropriate treatment, and management. A key challenge for the practitioner, particularly in cases where the illness can present atypically, is distinguishing bacterial tonsillitis infections from early acute IM. The ability to draw on timely, clear, and insightful laboratory results to distinguish viral from bacterial infection is vital. Correct and prompt diagnosis of IM can help prevent the unnecessary administration of antibiotics and mitigate the need for other expensive exploratory tests in cases of IM that present with splenomegaly, lymphadenopathy, or suspect haematological conditions. Good communication between the requesting clinician and those carrying out the investigative process, and between the different laboratory departments involved, is good practice and would ultimately benefit the patient. This communication will comprehensively review the aetiology, clinical presentation, and laboratory findings in IM with a view to promoting further research and so derive a standard diagnostic algorithm of the condition.

Spontaneous Splenic Rupture in an Ill Returned Traveller

Spontaneous splenic rupture is a known, but rare and possibly fatal, complication of different infectious diseases. We present a case of a 38-year-old male patient who presented with fever, icterus and spontaneous splenic rupture after a visit to Vietnam and discuss the differential diagnosis of splenic rupture in ill returned travellers.

Infectious mononucleosis complicated by peritonsillar abscess and postural orthostatic tachycardia syndrome: A case report

An unusual case of infectious mononucleosis complicated by both peritonsillar abscess and postural orthostatic tachycardia syndrome is reported. The patient was diagnosed with Epstein-Barr virus infection early in the disease course by her primary care doctor. She subsequently developed a peritonsillar abscess requiring hospitalisation. Recovery was complicated by the development of postural orthostatic tachycardia syndrome. However, resolution was achieved over the course of approximately 1 year, via conservative measures including graded exercise therapy, without resorting to pharmacotherapy.

Spontaneous splenic rupture in a patient with infectious mononucleosis

We present a case of spontaneous, atraumatic splenic rupture secondary to Epstein-Barr virus (EBV) infection, in a young, female patient. Splenic rupture is a rare complication of EBV infection, but is associated with the highest mortality. Additionally, this case illustrates the diagnostic challenge in a patient presenting in atypical manner, with only left-sided pleuritic chest pain, and lacking any of the classical tonsillitis symptoms associated with EBV infection.

Association of Splenic Rupture and Infectious Mononucleosis: A Retrospective Analysis and Review of Return-to-Play Recommendations

BACKGROUND

Infectious mononucleosis is typically a self-limited disease commonly affecting young adults. Splenic rupture is a rare but serious complication affecting 0.1% to 0.5% of patients with mononucleosis. Current guidelines (based on published case reports) recommend complete activity restriction for 3 weeks after onset of mononucleosis symptoms to reduce rupture risk. We examined actual timing of mononucleosis-associated splenic injury using a large repository of unpublished patient data.

HYPOTHESIS

The risk of splenic injury after infectious mononucleosis will remain elevated longer than previously estimated.

STUDY DESIGN

Retrospective case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

The Military Health System Management Analysis and Reporting Tool (M2) was used to conduct a retrospective chart review. Coding records of TRICARE beneficiaries aged 5 to 65 years between 2006 and 2016 were screened. Patients diagnosed with both splenic injury and mononucleosis-like symptoms were identified, and their medical records were reviewed for laboratory confirmation of infection and radiographically evident splenic injury.

RESULTS

A total of 826 records of splenic injury were found in M2. Of these, 42 cases met the study criteria. Mean time to splenic injury was 15.4 (±13.5) days. Only 73.8% (n = 31) of injuries occurred within 21 days, and 90.5% (n = 38) of splenic injuries occurred within 31 days of symptom onset.

CONCLUSION

A substantial number of splenic injuries occur between 21 and 31 days after symptom onset. While most splenic injuries were atraumatic, consideration should be given to extending return-to-play guidelines to 31 days after symptom onset to minimize risk. Risk of chronic pain after splenic injury may be higher than previously believed.

CLINICAL RELEVANCE

The risk for postmononucleosis splenic injuries remains elevated longer than current guidelines suggest. Restricting activity for 31 days after mononucleosis symptom onset may reduce the risk of splenic injury.

Epstein-Barr virus and its association with disease - a review of relevance to general practice

BACKGROUND

General practitioners encounter the vast majority of patients with Epstein-Barr virus-related disease, i.e. infectious mononucleosis in children and adolescents. With the expanding knowledge regarding the multifaceted role of Epstein-Barr virus in both benign and malignant disease we chose to focus this review on Epstein-Barr virus-related conditions with relevance to the general practitioners. A PubMed and Google Scholar literature search was performed using PubMed's MeSH terms of relevance to Epstein-Barr virus/infectious mononucleosis in regard to complications and associated conditions.

MAIN TEXT

In the present review, these included three early complications; hepatitis, splenic rupture and airway compromise, as well as possible late conditions; lymphoproliferative cancers, multiple sclerosis, rheumatoid arthritis, and chronic active Epstein-Barr virus infection. This review thus highlights recent advances in the understanding of Epstein-Barr virus pathogenesis, focusing on management, acute complications, referral indications and potentially associated conditions.

CONCLUSIONS

Hepatitis is a common and self-limiting early complication to infectious mononucleosis and should be monitored with liver tests in more symptomatic cases. Splenic rupture is rare. Most cases are seen within 3 weeks after diagnosis of infectious mononucleosis and may occur spontaneously. There is no consensus on the safe return to physical activities, and ultrasonic assessment of spleen size may provide the best estimate of risk. Airway compromise due to tonsil enlargement is encountered in a minority of patients and should be treated with systemic corticosteroids during hospitalization. Association between lymphoproliferative cancers, especially Hodgkin lymphoma and Burkitt lymphoma, and infectious mononucleosis are well-established. Epstein-Barr virus infection/infectious mononucleosis as a risk factor for multiple sclerosis has been documented and may be linked to genetic susceptibility. Chronic active Epstein-Barr virus infection is rare. However, a general practitioner should be aware of this as a differential diagnosis in patients with persisting symptoms of infectious mononucleosis for more than 3 months.

Splenic Infarction in Acute Cytomegalovirus and Human Parvovirus Concomitant Infection

We present a case report of a 35-year-old woman who had splenic infarction. She had persistent high fever, systemic joint pain, and abnormal liver function. She was diagnosed with cytomegalovirus and human parvovirus B19 concomitant infection. Her coagulopathy test revealed no abnormal results. She was treated with intravenous ganciclovir for 13 days; consequently, her splenic infarction improved after 7 weeks. As per our knowledge, this is the first case of cytomegalovirus and parvovirus B19 coinfection complicated by splenic infarction. Cytomegalovirus and parvovirus B19 may induce a hypercoagulation state during the acute phase.

Systematic review of spontaneous splenic rupture in dengue-infected patients

Dengue infection varies from a mild febrile form to more severe disease with plasma leakage, shock, and multiorgan failure. Several serious complications such as cardiomyopathy, encephalopathy, encephalitis, hepatic damage, and neural manifestations cause organ damage in dengue infection. Splenic rupture, a less well known but life-threatening complication, can occur in dengue. The mechanism of splenic rupture in dengue is still unclear. Optimal therapeutic management is required to save the lives of patients with this complication. The objective of this study was to conduct a systematic review of studies documenting the development of spontaneous nontraumatic splenic rupture in patients with dengue infection. In March 2018, a search was conducted systematically in nine electronic databases, in addition to hand- searching. A total of 127 references were exported to Endnote; 47 references remained after removing duplicates. Finally, 16 reports met the inclusion criteria and represented 17 cases. All articles were evaluated and data extracted according to predefined criteria: number of cases, age, sex, severity of dengue disease, days of illness before admission, methods of definitive diagnosis, timing of the event, and management and outcome. A total of 17 individual patients including 13 males and four females were found. Most of the patients were young adults (ranging from 20 to 52 years) and diagnosed with computed tomography scan and managed with splenectomy. Four cases were fatal. Pathological splenic rupture in dengue is a rare, life-threatening condition where timely management can achieve a favorable outcome.

Infections of the Oropharynx

This article reviews the presentation, diagnosis, and management of common and "can't miss" infections of the oropharynx, including streptococcal pharyngitis, infectious mononucleosis, peritonsillar abscess, retropharyngeal abscess, and epiglottitis.

Spontaneously Ruptured Spleen Samples in Patients With Infectious Mononucleosis: Analysis of Histology and Lymphoid Subpopulations

OBJECTIVES

Spontaneous rupture of the spleen is occasionally seen as the presenting event in infectious mononucleosis (IM). Diagnosis of these cases can be very challenging.

METHODS

We describe the morphologic and immunohistochemical findings in a series of seven splenectomy specimens removed after spontaneous rupture in patients with IM. Most cases were submitted for a second opinion since the histology of the cases suggested malignant lymphoma.

RESULTS

All the cases showed similar findings, with red pulp expansion occupied by activated T and B cells, including scattered large lymphocytes with both T- and B-cell markers, together with a polymorphic background rich in cytotoxic T cells. Clonality analysis revealed T-cell receptor clonal patterns in four of the six cases evaluated.

CONCLUSIONS

IM should be considered a possible diagnosis in any case of splenic rupture whose histology suggests possible aggressive lymphoma.

Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics

BACKGROUND

Pharyngitis is a common disease in the emergency department (ED). Despite a relatively low incidence of complications, there are many dangerous conditions that can mimic this disease and are essential for the emergency physician to consider.

OBJECTIVE

This article provides a review of the evaluation and management of group A β-hemolytic Streptococcal (GABHS) pharyngitis, as well as important medical conditions that can mimic this disease.

DISCUSSION

GABHS pharyngitis often presents with fever, sore throat, tonsillar exudates, and anterior cervical lymphadenopathy. History and physical examination are insufficient for the diagnosis. The Centor criteria or McIsaac score can help risk stratify patients for subsequent testing or treatment. Antibiotics may reduce symptom duration and suppurative complications, but the effect is small. Rheumatic fever is uncommon in developed countries, and shared decision making is recommended if antibiotics are used for this indication. Oral analgesics and topical anesthetics are important for symptom management. Physicians should consider alternate diagnoses that may mimic GABHS pharyngitis, which can include epiglottitis, infectious mononucleosis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and viral pharyngitis. A focused history and physical examination can help differentiate these conditions.

CONCLUSIONS

GABHS may present similarly to other benign and potentially deadly diseases. Diagnosis and treatment of pharyngitis should be based on clinical evaluation. Consideration of pharyngitis mimics is important in the evaluation and management of ED patients.

Confusion and abdominal symptoms following a rugby tackle

A 19-year-old man was sent to the emergency department following a pitch-side assessment for suspected concussion, unexplained upper abdominal tenderness and vomiting, following a high-impact tackle during a rugby match. A Focussed Assessment with Sonography for Trauma (FAST) scan performed in the emergency department suggested intra-abdominal free fluid, and subsequent head and abdominal CT imaging showed no intracranial lesion but confirmed a significant haemoperitoneum due to large splenic tear and bleeding. An emergency splenectomy was performed, which confirmed the rupture of an enlarged spleen with blood loss of almost 2 L into the peritoneal cavity. The patient made a full recovery following surgery. A subsequent histological examination revealed granulomatous inflammation characteristic of infectious mononucleosis. This unique case illustrates that physically fit patients with early hypovolaemic shock can present with symptoms mimicking concussion.

Epstein-Barr virus and cytomegalovirus mononucleosis: Important causes of febrile illness in returned travellers

BACKGROUND

Diagnosing the cause of fever in the returned traveller is challenging. Efforts often focus on identifying 'exotic' pathogens. Primary Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections cause clinical features that overlap with many exotic pathogens. The age-matched seroprevalence of both EBV and CMV is greater in tropical than temperate areas. We describe the clinical and laboratory features of returned travellers diagnosed with primary CMV and EBV syndromes.

METHODS

Patients with laboratory-confirmed primary EBV and CMV infections who had attended the Hospital for Tropical Diseases (HTD), London between 1st October 2011 and 1st October 2016 were identified. Clinical and laboratory data were obtained and analysed.

RESULTS

Twenty-two patients with primary EBV infection and 31 with primary CMV infection were identified. The commonest presenting features of both infections were fever (81.1%), headache (50.9%) and arthralgia/myalgia (49.1%). Cervical lymphadenopathy was seen more frequently with EBV than with CMV (59.1% vs. 25.8%, P = 0.02). Transaminitis (79.2%) and lymphocytosis (52.8%) were the commonest laboratory abnormalities in both groups.

CONCLUSIONS

Primary EBV and CMV infections are important causes of febrile illness in returning travellers. Identification of these pathogens prevents unnecessary, expensive investigations for more 'exotic' pathogens and impacts clinical management for example facilitating prognostication and antimicrobial stewardship.

Familial spontaneous splenic rupture in a patient with idiopathic splenomegaly-report of a case

Spontaneous splenic rupture in a healthy individual is a rare phenomenon. This article reports on a patient with an uneventful medical history, presenting with atraumatic splenic rupture. Three family members of the patients experienced the same in the past.

Gastrointestinal considerations related to youth sports and the young athlete

Young athletes, though often healthy, can carry a variety of symptoms that may impede their participation in sports or other activities. Typically we might think of musculoskeletal and respiratory problems primarily, however disorders of the gastrointestinal (GI) tract must also be considered. In some instances musculoskeletal complaints may bring to light activity of an underlying GI condition as is the case with inflammatory bowel disease. Gastrointestinal symptoms in the young athlete can be quite significant and a nuisance for participation. We aim to describe and discuss treatment options of a few conditions targeted specifically for your young athlete both that arise specifically from athletic participation and those GI disorders that are chronic in nature whose presence must not be neglected in the athlete.

Fluorescence in situ hybridization is superior for monitoring Epstein Barr viral load in infectious mononucleosis patients

BACKGROUND

Epstein Barr virus (EBV) plays a causal role in some diseases, including infectious mononucleosis, lymphoproliferative diseases and nasopharyngeal carcinoma. Detection of EBV infection has been shown to be a useful tool for diagnosing EBV-related diseases. In the present study, we compared the performance of molecular tests, including fluorescence in situ hybridization (FISH) and EBV real-time PCR, to those of serological assays for the detection of EBV infection.

METHODS

Thirty-eight patients with infectious mononucleosis (IM) were enrolled, of whom 31 were diagnosed with a mild type, and seven were diagnosed with IM with haemophagocytic lymphohistiocytosis and chronic active EBV infection. Twenty healthy controls were involved in the study. The atypical lymphocytes in peripheral blood were detected under a microscope and the percentage of positive cells was calculated. EBV DNA load in peripheral blood was detected using real-time PCR. The FISH assay was developed to detect the EBV genome from peripheral blood mononuclear cells (PBMC). Other diagnosis methods including the heterophil agglutination (HA) test and EBV-VCA-IgM test, to detect EBV were also compared. SPSS17.0 was used for statistical analysis.

RESULTS

In all, 5-41% atypical lymphocytes were found among the PBMC in mild IM patients, whereas 8-51% atypical lymphocytes were found in IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients. There was no significant difference in the ratios of atypical lymphoma between patients of the different types. We observed that 71.2% of mild IM patients and 85.7% of IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients were positive for EBV-VCA-IgM. EBV-VCA-IgM was negative in all healthy control subjects. In addition, 67.1% of mild IM patients tested heterophile antibody positive, whereas 71.4% of IM patients with haemophagocytic lymphohistiocytosis and chronic active EBV infection tested positive. EBV DNA detected using real-time PCR was observed in 89.5% of these IM patients. The EBV genome was detected by the FISH assay in 97.4% of the IM patients. The EB viral loads detected by FISH and real-time PCR increased with the severity of IM. The EBV genome was detected in almost all the PBMC of IM with haemophagocytic lymphohistiocytosis and chronic active EBV infection patients.

CONCLUSION

Molecular tests, including FISH and EBV real-time PCR, are more sensitive than serological assays for the detection of EBV infection. The FISH assay detecting EBV copies in unfractionated whole blood is preferable and superior to plasma real-time PCR in its reflection of the absolute viral burden circulating in the patients.

Atraumatic splenic rupture secondary to Epstein-Barr virus infection

We present a case report of atraumatic splenic rupture secondary to Epstein-Barr virus (EBV) infection. A woman aged 36 years presented to a London teaching hospital's Accident and Emergency department with severe abdominal pain following a 6-day history of diarrhoea and vomiting, which had been under review by her GP. A CT scan demonstrated free intraperitoneal fluid and abnormal appearance of her spleen. Blood tests demonstrated EBV infection with positive serology and leucocytosis. She underwent a laparoscopic washout, which confirmed a subcapsular splenic haematoma that was initially managed conservatively. However, she subsequently re-presented with increasing pain and required an elective splenectomy. This case demonstrates the risk of splenic rupture following EBV infection, even in the absence of trauma, and highlights the importance of prompt diagnosis and appropriate counselling in patients with infectious mononucleosis.

Spontaneous Splenic Rupture Caused by Scrub Typhus

Spontaneous rupture of the spleen is rarely described as a complication of scrub typhus infection. We report a previously healthy 74-year-old Thai female farmer who presented in Nakhon Ratchasima, Thailand, with a history of fever and malaise for 5 days, followed by abdominal pain for 1 day. An exploratory laparotomy was performed due to peritonitis. Operative findings revealed a ruptured spleen and hemoperitoneum. A splenectomy was performed afterward. Scrub typhus was confirmed by a 4-fold increase of IgM titer using an indirect immunofluorescence antibody assay and a positive result from the polymerase chain reaction targeting the 47- and 56-kDa genes in Orientia tsutsugamushi She responded well to intravenous chloramphenicol and defervesced within 24 hours without any complication.

Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection

The purpose of this study was to report a case of a previously healthy 20-year-old woman diagnosed with splenic infarction following infectious mononucleosis (IM) by Epstein-Barr virus (EBV) infection and to perform the first systematic review of the clinical characteristics of splenic infarction associated with IM. A systematic review was conducted using English, French, and Japanese literatures of splenic infarction associated with IM due to EBV infection published between 1961 and 2015 in PubMed Medline. A total of 19 cases were extracted from the collected articles. Left upper quadrant (LUQ) pain was observed in 15 (79%) patients. Splenectomy was performed in five (26%) cases, among which four patients presented with stable vital signs. Splenic rupture was accompanied in two (10%) patients. The median time from the onset of IM symptoms to the diagnosis of splenic infarction was 5 days (range, 1-25 days). Fourteen (74%) of 19 patients experienced improvement through medical treatment, and there were no deaths. Splenic infarction associated with IM due to EBV infection can show a favorable clinical outcome after medical treatment. Clinicians should consider the possibility of splenic infarction when patients with IM experience LUQ pain. J. Med. Virol. 89:332-336, 2017. © 2016 Wiley Periodicals, Inc.