Title : A rare case of spontaneous splenic rupture in a young patient with infectious mononucleosis
Abstract:
We present a case of 34 y old male who initially presented to emergency department with multiple episodes of vomiting and diarrhoea accompanied by lower urinary tract symptoms. There was no history of binge alcohol intake, eating takeaway food or travel. On review of his observations heart rate was 128, temperature was 37.8 and blood pressure was 110/73. Upon systemic review chest was clear, abdominal examination revealed left lower quadrant and suprapubic tenderness. His rest of examination were unremarkable. On review of his blood tests, lactate was 2.8 (0.6-2.5) mmol/L, CRP 39 (0-5) mg/L, WCC of 14.2 (4-11) 10*9/L Hb 83 (130-180) g/L , lymphocyte 8.2 (1-4) 10*9/L, bilirubin 26 (0-20) umol/L, ALT 211(0-55) U/L and ALP 468 (30-130) U/L, amylase 38(28-100) U/L ,Glucose 6.4 (4-11) mmol/L, eGFR >90 (90-120) mL/min, creatinine 109 (64-104) umol/L, urea 5.5 (2.5-7.8) mmol/L and normal electrolytes. His Chest x-ray was clear.
Initially seen by out of hours GP and referred to medicine. He was seen by Emergency team and handed over to medicine team after administration of Intravenous fluids. Upon review of medical team impression was sepsis likely source urinary tract infection and he was given IV broad spectrum antibiotics, IV fluids and blood cultures has been sent off. His CT abdomen pelvis was requested to look for hepatobiliary source of infection due to deranged LFTs which showed splenomegaly with a large sub capsular splenic hematoma and likely free blood within abdomen suggestive of splenic rupture He was referred to surgical team for ongoing management and they had kindly accepted the referral. As part of work up for splenomegaly and deranged liver function tests EBV screen was done which later on turned out to be positive for IgM and EBV viral load .His CT triple phase abdomen pelvis was done to check suitability for IR embolization after 3 hours of initial CT which revealed unchanged volume of blood since previous CT with no evidence of active bleeding. He was kept under observation
Day 1: He was transfused with 2 units of bloods, haemoglobin monitored and started on soft diet.
Day 2: Haemoglobin continued to drop despite 2 units of transfusion and decided to re do CT abdomen and pelvis.
Day 3: His CT angiogram renal and abdominal was done due to ongoing drop in haemoglobin which revealed active splenic haemorrhage with interval increase in size of haematoma.
Day 4: He underwent IR splenic artery
Following IR embolization he was kept under observation for few days and then discharged Following a brief period of recovery from hospital.
Conclusion: Splenic rupture is a rare complication of infectious mononucleosis. Although it occurs only in 0.1%-0.5% of cases, splenic rupture remains the most common fatal complication of the disease. Mononucleosis related spontaneous rupture of the spleen without any other characteristic symptoms of the disease is extremely unusual and threatens with fatal outcome due to its rare learning in this case was left lower quadrant pain should have prompted abdominal imaging as it wouldn’t have been explained by D & V and presentation.
