Teenage kicks: splenic rupture secondary following infectious mononucleosis

Abstract

A 16-year-old man was brought to the emergency department by his father with apparent alcohol intoxication. While in the department, it was noted that the patient had ongoing tachycardia, hypotension and abdominal pain. His recent medical history included a self-resolving illness of fatigue, muscle aches and sore throat. A CT scan of his abdomen revealed an enlarged spleen with a splenic infarct and rupture, likely secondary to infectious mononucleosis. The patient was treated conservatively for 12 days.

Background

This is an important case for all emergency medicine physicians. It highlights the fact that intoxicated patients are a high-risk group who may be masking other pathologies. It is essential to take a detailed history and perform accurate examination on all intoxicated patients presenting to the emergency department. Intoxicated patients should be re-evaluated once they can reliably respond to questioning. The case also describes a rare complication of infectious mononucleosis, that is, splenic rupture. This has implications for the advice we give our patients regarding not returning to contact activities after a diagnosis of infectious mononucleosis.

Case presentation

A 16-year-old man was presented to the emergency department following ingestion of alcohol. His father was concerned regarding the patient’s low conscious level. He had been at a party with friends and had admitted to drinking up to 500 mL of vodka. He had no significant past medical history, but it was noted that he had been suffering from a non-specific illness the previous week. He had been complaining of sore throat, generalised muscle aches and fatigue. His girlfriend had also been unwell with a similar illness over the previous 3 days. The patient’s symptoms had resolved spontaneously, and he had been feeling well for 2 days prior to his presentation.

On examination, he was drowsy but orientated. His Glasgow Coma Scale was 14/15; he required verbal stimulation for eye opening. His vital signs revealed a mild tachycardia at a rate of 109 bpm, and a blood pressure of 109/64 mm Hg. His temperature was 36.9°C, and his oxygen saturation and respiratory rate were normal. His cardiovascular and respiratory examinations were normal. Examination of his abdomen revealed tenderness in the epigastrium and left upper quadrant with a palpable splenic edge 2 cm below the costal margin.

A diagnosis was made of infectious mononucleosis in combination with alcohol intoxication. Blood tests were taken, and the patient was treated with intravenous crystalloid fluid. He was observed overnight. The patient was reassessed in the morning. He had ongoing left upper quadrant tenderness, tachycardia and hypotension. His history was reviewed once he was able to cooperate with questioning. He described having partaken in a game with friends where punches were exchanged to each other’s abdomens. His blood results revealed a leukocytosis (white cell count 20.3x10⁹/L) with a predominant rise in lymphocytes (15.0x10⁹/L), his haemoglobin was 133g/L, and all other blood results were normal.

Following this extra piece of information, a CT scan of the patient’s abdomen was arranged (figure 1). This revealed an acute splenic rupture with signs of splenic enlargement and infarcts likely secondary to infectious mononucleosis (figure 2).

Figure 1.

Axial CT scan of abdomen.

Figure 2.

Coronal CT scan of abdomen.

Investigations

ECG: sinus tachycardia.

Chest X-ray: normal.

CT scan: enlarged spleen with infarcts and acute splenic rupture.

Monospot: positive.

Differential diagnosis

Spontaneous versus traumatic splenic rupture postinfectious mononucleosis infection.

Treatment

The patient was treated conservatively under the surgical team. He was given antiemetic medication and analgesia. His haemoglobin dropped to a low of 97 g/L 2 days postinjury, but settled spontaneously.

Outcome and follow-up

The patient remained in hospital for 12 days during which he had two further CT scans, which showed partial resolution of his splenic injury and abdominal free fluid. His monospot was positive during his stay as an inpatient. He was discharged to outpatient care following an uncomplicated inpatient stay.

Discussion

Alcohol-related presentations are common in emergency medical care.¹ This cohort of patients provides a diagnostic challenge in terms of identifying those who may be masking other associated pathologies. This is often due to doctors underestimating these patient’s complaints or falsely attributing signs and symptoms to alcohol ingestion. This can result in delayed or missed diagnosis.

We reached the diagnosis in our case due to a high clinical suspicion, which ensured serial examinations were performed. These can be difficult principles to follow especially in an uncooperative patient.

Our patient suffered a splenic rupture secondary to infectious mononucleosis. It is difficult to determine if this was a case of spontaneous or traumatic rupture, as the patient could not fully remember the events of the night but did admit to possibly participating in some activities the night before, which may have resulted in him sustaining blunt trauma to the abdomen.

Splenic rupture is a rare complication of infectious mononucleosis with the incidence being <1%.^{2 3} The traditional method of treatment was for operative removal of the spleen, but the role of non-operative management is evolving to the level where it is more appropriate for patients who are relatively stable.^4–6

The risk of rupture is largest in the first 3 weeks postinfection and is relative to the size of splenic enlargement.² Currently, there is no consensus on when patients may return to contact activities. Recent literature advises an individualised approach based on severity and length of symptoms combined with radiological findings. Patients should be advised to abstain from contact activities for at least 1 month prior to return. This may be prolonged if the spleen remains enlarged, or the patient remains symptomatic.^{7 8}

Learning points.

• No intoxicated patient should be discharged without a thorough examination being performed.

• Splenic rupture should be considered in any patient with abdominal pain post viral infection.

• Patients should be advised to avoid contact activities for at least 4 weeks following a diagnosis of infectious mononucleosis.

• Patients who suffer splenic rupture following infection with infectious mononucleosis may be treated conservatively.