Identification of splenic infarction by emergency department ultrasound

Splenic Infarction Due to Epstein-Barr Virus: A Case Report and Literature Review

Splenic infarction is a rare and likely underdiagnosed complication of Epstein-Barr virus (EBV)-associated infectious mononucleosis (IM). Here, we describe an 18-year-old Guyanese male with persistent severe left-sided abdominal pain found to be EBV positive and have a large splenic infarct, along with a transient decrease in protein C, protein S, and antithrombin III activity levels. He was treated with supportive care and anticoagulated with heparin and apixaban. We review prior reports and perspectives on underlying pathophysiology, diagnosis, and the management of these cases, which likely do not require anticoagulation but may be considered on a per-case basis.

Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review

BACKGROUND

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is one of the most common pathogenic viruses in humans. EBV mononucleosis always involves the spleen and as such it predisposes to splenic rupture, often without a trauma, and splenic infarction. Nowadays the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections.

METHODS

To characterise these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible articles were those describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis.

RESULTS

In the literature, we found 171 articles published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (n = 139) of cases occurred within three weeks of the onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery splenic rupture score, which was retrospectively calculated, and surgical management: splenectomy in 84% (n = 44) of cases with a severe score and in 58% (n = 70) of cases with a moderate or minor score (p = 0.001). The mortality rate of splenic rupture was 4.8% (n = 9). In splenic infarction, an underlying haematological condition was observed in 21% (n = 6) of cases. The treatment of splenic infarction was always conservative without any fatal outcomes.

CONCLUSIONS

Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a pre-existing haematological condition.

Infectious Mononucleosis-Induced Splenic Infarction: Perhaps More Common in Healthy Individuals Than Previously Thought

Infectious mononucleosis (IM) is a clinical syndrome that presents as a triad of fever, pharyngitis, and lymphadenopathy. In most cases, it is caused by the Epstein-Barr virus (EBV), which spreads through upper respiratory secretions, particularly saliva, earning its name as the Kissing Disease. In most cases, IM is self-limiting and resolves in two to four weeks without significant sequelae following supportive care. Although rare, IM has been associated with several serious and sometimes life-threatening complications, involving almost any organ system. Splenic infarction is one rare complication of IM due to EBV infection. In the past, IM-induced splenic infarction in the setting of EBV was believed to be rare and mostly limited to patients with underlying hematologic comorbidities. However, we propose this condition to be more common and more likely to occur in individuals without significant medical history than previously suspected. We report a relatively healthy young male patient in his thirties, with no previous history of coagulopathy or complex medical conditions, who was found to have IM-induced splenic infarction.

Infectious Mononucleosis Complicated with Bilateral Peritonsillar Abscess and Splenic Infarction

Infectious mononucleosis (IM) due to Epstein–Barr virus (EBV) infection is usually self-limited. It presents with fever, pharyngitis, fatigue, and cervical lymph node enlargement. It is common among adolescents and young adults. Although most patients recovered without any sequelae, rare complications have been reported. We described a 28-year-old man with fever, sore throat, dysphagia, and a positive IgM viral capsid Ag (VCA Ag) for EBV infection. He was admitted and received dexamethasone. He developed bilateral peritonsillar abscess (PTA) and splenic infarction, rare complications of acute EBV infection, two days after discharge. Although early reports noted PTA might occur following dexamethasone administration, recently, no obvious evidence supports it. However, high erythrocyte sedimentation rate level in our patient might indicate bacterial superinfection, which could exacerbate with dexamethasone administration. Several mechanisms such as transient hypercoagulable state and insufficient blood supply due to splenomegaly were proposed for splenic infarction due to EBV infection. Since our patient remained asymptomatic during the disease, IM-associated splenic complications, including splenic infarction, should be kept in mind. Our patient underwent bilateral tonsillectomy and received conservative management for the splenic infarction. These two rare complications of acute EBV infection have not been reported simultaneously yet.

A Mysterious Case of an Infarcted Spleen due to Kissing Disease: A Rare Entity

Viruses are long known to be leading causes of self-limiting infections. Infectious mononucleosis (IM) caused by the Epstein-Barr virus (EBV) is, however, no exception. The ailment is caused by a DNA virus belonging to the Herpesviridae family. As stated earlier, the infection is usually self-limited with mononucleosis-like symptoms such as fever, sore throat, lymphadenopathy (LAD), rash, headache, etc. In rare instances, it can lead to severe complications. The organ of prime importance following the infection is spleen. There are occasions where splenic injuries can lead to rupture, deeming to emergency surgical interventions. At other times, a rare entity may also be seen that constitutes an infarction within the splenic substance. We present this rare finding in a 20-year-old male patient with a left upper quadrant (LUQ) pain, cervical LAD, and sore throat who was brought to the emergency department. On physical examination, mild tenderness was observed in the LUQ with an inflamed throat and palpable cervical and occipital lymph nodes. Laboratory investigations suggested lymphocytosis with no blast cells, lactic acidosis, and mild acute kidney injury. A contrast-enhanced computed tomography scan demonstrated an enlarged spleen with wedge-shaped hypodense areas, which led to a diagnosis of splenic infarction secondary to infectious mononucleosis. Keeping in mind the symptomatology and the age of the patient, a bunch of differentials were needed to be ruled out. Out of a series of investigations done on the patient, EBV serology for IgM was positive. The patient was conservatively treated with a complete resolution of symptoms in one month. Our case adds to the literature the finding of a rare etiology of splenic infarction secondary to IM and the importance of stepwise and cost-effective investigations to avoid unnecessary workup when needed.

[Usefulness and reliability of abdominal point of care ultrasound in family practice (2): Large abdominal vessels, spleen, nephrourological and gynecological ultrasound]

This article is a continuation of the review initiated in the previous issue about the usefulness of point of care ultrasound in Primary Care, completing the scenarios of large abdominal vessels, spleen, nephrourological and gynecological ultrasound.

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.

The unexpected finding of a splenic infarction in a patient with infectious mononucleosis due to Epstein-Barr virus

The authors present a case of a 24-year-old man with infectious mononucleosis (IM) due to Epstein-Barr virus (EBV). Among his symptoms, he reported abdominal pain in the upper left quadrant. An abdominal ultrasound and CT revealed an extensive splenic infarction. During the acute stage of this disease, the thrombophilic screening revealed reduced free protein S and elevated factor VIII, with normalisation on re-evaluation 6 weeks later. Splenic infarction is a very rare complication of IM due to EBV but should be considered in patients presenting abdominal pain. A hypercoagulability state should be investigated. To our knowledge, this is the first described case of a splenic infarction in a patient with IM due to EBV associated with a transient reduction of protein S and elevation of factor VIII. Thus, this work promotes the importance of including these factors in the thrombophilic screening conducted during the investigation of similar cases.

The sonographic "bright band sign" of splenic infarction

OBJECTIVES

To evaluate the frequency of the "bright band sign" in patients with splenic infarcts as well as control patients and to thereby assess whether the bright band sign has potential utility as a sonographic sign of splenic infarction.

METHODS

Using an electronic search engine and image review, 37 patients were retrospectively identified with noncystic parenchymal splenic infarcts on sonography. Nineteen abnormal control patients with noninfarcted splenic lesions on sonography and 100 normal control patients with sonographically normal spleens were also identified. The sonographic appearance of each splenic lesion was evaluated by 2 reviewers and assessed for the bright band sign, defined as thin specular reflectors perpendicular to the sound beam within hypoechoic parenchymal lesions, and for the presence or absence of the classic sonographic appearance of splenic infarction. Possible histologic counterparts of the bright band sign were assessed in archival infarct specimens.

RESULTS

The bright band sign was present in 34 (91.9%; 95% confidence interval [CI], 78.1%-98.3%) of 37 patients with splenic infarcts on sonography, including 12 (85.7%; 95% CI, 57.2%-98.2%) of 14 with classic and 22 (95.7%; 95% CI, 78.1%-99.9%) of 23 with nonclassic infarct appearances. No normal or abnormal control patients had the bright band sign. Histologic sections suggested that preserved splenic trabeculae within infarcts may generate the bright band sign.

CONCLUSIONS

The bright band sign is a potentially useful sonographic sign of splenic infarction, which may confer additional sensitivity and specificity and may be particularly helpful with infarcts having nonclassic appearances.