Chapter 31 Splenomegaly in a 40-Year-Old Female (Case 19)
PATIENT CARE
Clinical Thinking
• The proper workup for splenomegaly will delineate whether it is directly related to the spleen or if the splenic enlargement is secondary to an underlying disease process.
• Realize that most patients do not even know where their spleen is, nor do they know anything about its function. When evaluating a patient with splenomegaly, anticipate that a significant amount of patient education will be required.
• The patient undergoing splenectomy will be at risk for future infection. The most common organisms that cause infections/sepsis after splenectomy are Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitis. If possible, H. influenzae type B, meningococcal, and pneumococcal vaccines should be administered 2 weeks prior to splenectomy; otherwise, vaccination 2 weeks following surgery is acceptable. As the risk for post-splenectomy sepsis is highest in the first year after surgery, patients must be advised to be cautious when dealing with any minor infection or illness.
History
• Why were you asked to see the patient? Was the enlarged spleen noted because of “B” symptoms (fevers, chills, night sweats), pain, or early satiety, or is splenomegaly an incidental finding? If splenomegaly is an incidental finding on a CT of the abdomen, what was the indication for the test?
• Review of systems should include a hx of trauma, abdominal pain, foreign travel, easy bruising or bleeding, weight loss or gain, and sexual hx.
Physical Examination
• Normally the spleen rests under the tenth and eleventh rib on the left. The average spleen is 12 cm by 7 cm. It needs to be substantially larger than that to be palpated by most clinicians.
• A thorough abdominal examination with gentle but deep palpation is performed. A palpable mass in the left upper or lower quadrant of the abdomen should be suspicious for the spleen. When suspecting splenomegaly, begin palpating low in the abdomen, lest the tip of a massive spleen be missed.
Tests for Consideration
| $80 | |
| $75 |
| Clinical Entities | Medical Knowledge |
|---|---|
| Infectious Mononucleosis | |
| PΦ | Infectious mononucleosis is a viral disease (Epstein-Barr virus) that is spread from human to human by close physical contact. The inflammatory response and increased circulating blood monocytes can lead to splenic engorgement. |
| TP | The typical patient will have an incubation period where only a sore throat is present. As the illness progresses, the patient may develop fever, malaise, and myalgias. Eventually splenic enlargement may lead to early satiety and/or LUQ pain due to stretching of the splenic capsule. |
| Dx | Dx is made by the heterophile test or Monospot test. |
| Tx | The disease is usually self-limiting. The most concerning problem relating to the spleen is spontaneous splenic rupture (0.5% of cases). Adolescents with mononucleosis should be advised to avoid vigorous physical activity and contact sports. If splenic rupture occurs, urgent splenectomy is the tx. |
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