Splenic infarction due to infectious mononucleosis

K Ashawesh, R Abdulqawi, BN Chandrappa, K.S. Srinivasan

Department of medicine, Princess Royal Hospital, Telford, TF1 6TF, UK

Corresponding address:  Dr Khaled Ashawesh, Department of medicine, Princess Royal Hospital, Telford, TF1  6TF, UK

Email: k_ashawesh@yahoo.com

SMJ 2007 52(4): 54

 

Abstract

Splenic infarction due to Infectious mononucleosis is very uncommon. We describe a rare case of acute Epstein-Barr virus infection in which the patient presented with acute abdominal pain secondary to splenic infarction.

Keywords: splenic infarction; acute Epstein-Barr virus infection, infectious     mononucleosis.

 

Case report

A 30-year-old man with no significant past medical history was admitted with a three-day history of worsening left upper abdominal pain. He had been unwell for ten days prior to admission with fever, sweating, malaise and a sore throat. On examination, he had a temperature of 39.3 C, blood pressure 115/70 mm Hg and a pulse rate of 105 beats/minute. The oropharynx was red with bilateral nonpurulent tonsillitis. There was no lymphadenopathy. Abdominal examination revealed severe tenderness and guarding in the left hypochondrial area. Cardiovascular, respiratory and neurological examinations were unremarkable. A full blood count (FBC) showed: haemoglobin, 12.2 g/dl; platelet count, 242 × 109/L; white blood cell count, 14.4 × 109/L with 68% lymphocytes, 23% of which were atypical. His liver function tests (LFT’s) were abnormal with ALT 257 u/L (10-37), ALP 413 u/L (45-120), GGT 860 u/L (0-75), total bilirubin 41 umol/L (0-17), Albumin 33 g/L (36-48). Blood, urine and throat swap cultures were negative.  Serologic screening for cytomegalovirus, hepatitis A, B and C viruses were also negative. Chest X-ray was normal. Computerised tomographic (CT scan) of the abdomen revealed splenomegaly with multiple wedge-shaped low-attenuation areas, consistent with splenic infarction (Figures 1 & 2). Diagnosis of acute infectious monoucleosis (IM) was suspected and confirmed by a positive monospot test, positive Epstein-Barr Virus (EBV) viral capsid antigen IgG and IgM and a negative EBV nuclear antigen IgG. The patient’s symptoms improved with supportive treatment and he was discharged 7 days post admission. Eight weeks later at outpatient follow-up, he had made a full clinical recovery with normalisation of FBC and LFT’s.

Figures 1 & 2. CT of the Abdomen: The arrows indicate the areas of splenic infarction.

 

   

 

Discussion

IM is caused by EBV and commonly presents with classical triad of fever (76%), pharyngitis (84%) and cervical lymphadenopathy (94%).1 Other presenting features include: splenomegaly (52%), hepatomegaly (12%) and rash (10%).1 Splenic rupture is uncommon, occurring in 0.1-0.5% of patients.2 Diagnosis is usually confirmed by a positive Monospot test, which has 63%-84% sensitivity and 84-100% specificity.3 Measurement of EBV antibodies is typically reserved for cases with suspected false positive or negative monospot test results.  Splenic infarction during IM is very rare; to our knowledge, only five cases have previously been reported.4, 5, 6, 7, 8 The pathogenesis of splenic infarction during IM remains unclear. In one case report of IM associated with splenic infarction,4 transient elevation of antiphospholipid antibodies was found and thought to be responsible for the splenic infarct.

                                                                                                                               

Conclusion

Acute EBV infection should be considered in the differential diagnosis of splenic infarction. This diagnosis should also be considered in patients presenting with unexplained acute abdominal pain.

 

References

  1. Schooley RT, Dolin R. Epstein-Barr virus (infectious mononucleosis). In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and Practice of Infectious Diseases. Third edition. New York: Churchill Livingstone; 1990:1172-85.

  2. Rutkow IM. Rupture of the spleen in infectious mononucleosis: a critical review. Arch Surg 1978; 113: 718-20

  3. Linderholm M, Boman J, Juto P, Linde A. Comparative evaluation of nine kits for rapid diagnosis of infectious mononucleosis and Epstein-Barr virus-specific serology. J Clin Microbiol. 1994;32:259-61.

  4. Van Hal S, Senanayake S, Hardiman R. Splenic infarction due to transient antiphospholipid antibodies induced by acute Epstein-Barr virus infection. J Clin Virol. 2005;32:245-7.

  5. Kim KM, Kopelman RI. Medical mystery: abdominal pain--the answer. N Engl J Med. 2005;353:1421-2.

  6. Trevenzoli M, Sattin A, Sgarabotto D, et al. Splenic infarct during infectious mononucleosis. Scand J Infect Dis. 2001;33:550-1.

  7. Garten AJ, Mendelson DS, Halton KP. CT manifestations of infectious mononucleosis. Clin Imaging. 1992;16:114-6.

  8. Boivin P, Bernard JF. Pyruvate kinase deficiency, infectious mononucleosis, hemolytic anemia with cold autoantibodies and massive splenic infarction. Presse Med. 1990;19:818-9

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