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Pleuritic pain and a rare complication

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Q1: Given his history of haemoptysis and subsequent severe pleuritic pain, what further diagnosis would you consider and how would you treat this?

Given these symptoms, the hypoxia, and findings on electrocardiography the diagnosis of pulmonary embolism should be considered. Routinely this is treated with low molecular weight heparin and urgent V/Q scan is requested.

Q2: What condition was diagnosed from his computed tomogram (fig 2; see p 433) and what further management was indicated?

His abdominal computed tomogram appearances were in keeping with a splenic rupture with large associated haematoma. The condition he suffered was spontaneous rupture of spleen (SRS). He underwent emergency splenectomy. Operation revealed one litre of free fluid in the abdominal cavity with a fragmented spleen.

Q3: What did the laboratory find on reviewing this patient’s blood film?

Atypical lymphocytes.

Q4: What follow up testing did they perform and what diagnosis was made?

A Monospot test was performed and confirmed the diagnosis of infectious mononucleosis.

Q5: What is the significance of his shoulder discomfort?

Kehr’s sign is defined as pain and hyperasthesia over the left shoulder and may be due to splenic rupture.

Discussion

Spontaneous rupture of spleen is a rare complication of infectious mononucleosis with several documented cases,1 its incidence is between 0.1% to 0.5%,2 and other less common causes of SRS include influenza, rubella, tuberculosis, and lymphoma.3 It is a potentially life threatening complication.

This patient had typical clinical and radiological features of pneumonia. The subsequent diagnosis of pulmonary embolism was based on the presence of significant left pleuritic chest pain, previous haemoptysis, hypoxia, and slightly abnormal electrocardiography. The planned V/Q scan was not done as the patient had deteriorated. However he also had manifestations of infectious mononucleosis—sore throat, fever, anorexia, malaise, and dysphagia. Confirmation of infectious mononucleosis by Monospot was established at the time of SRS.

Learning points

  • Infectious mononucleosis can lead to the rare complication of SRS.

  • Beware of pleuritic pain in infectious mononucleosis. Chest pain accompanied by Kehr’s sign may be the only indication of SRS.

  • If infectious mononucleosis is suspected, syncope or a falling haemoglobin level should always be investigated by urgent ultrasound/computed tomography to check that there is no underlying SRS.

The largest review of infectious mononucleosis cases with SRS is a retrospective analysis by the Mayo clinic.1 The predominant features of SRS were left upper quadrant pain and tenderness, splenomegaly, and Kehr’s sign. Certainly in our case, Kehr’s sign was an initial complaint but did not remain a persistent feature. The Mayo clinic review also highlighted that abdominal pain may be a late presenting sign and that patients can have a low haemoglobin level or develop a marked drop in haemoglobin level.

The majority of patients with SRS undergo splenectomy.1,2,4 This patient underwent emergency splenectomy and in our opinion surgery was mandatory because of his falling haemoglobin level, persistent symptoms, and large splenic rupture. Some authors do advocate conservative management in SRS due to infectious mononucleosis1,2 but only with specified criteria such as haemodynamic stability and accurate transfusion assessment.

Another issue is the use of low molecular weight heparin and whether this was a precipitating factor for SRS. SRS has been reported in a patient who was on warfarin after myocardial infarction5; no other causal factor was identified. It is unlikely that the heparin used in this case was the main causal factor for SRS as the patient had already had symptoms and signs prior to treatment. However its use certainly would have exacerbated an already ruptured or weakened spleen.

The diagnosis of SRS is usually confirmed by abdominal ultrasound or computed tomography.

Final diagnosis

Spontaneous rupture of spleen secondary to infectious mononucleosis.

References

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