Advertisement

Woman with sore throat, fever and abdominal pain

  • Pierrick Le Borgne
    Correspondence
    Corresponding author at Pierrick Le Borgne (MD, MSc), Emergency Department, Strasbourg University Hospital, 1 Avenue Molière, 67200 Strasbourg, France
    Affiliations
    Emergency Department, Strasbourg University Hospital, Hautepierre Hospital, 1 Avenue Molière, 67200 Strasbourg, France

    INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), University of Strasbourg, France
    Search for articles by this author
  • Claudia Brunhuber
    Affiliations
    Diagnosezentrum Lahr, Turmstrasse 21, 77933 Lahr, Germany
    Search for articles by this author
  • Pascal Bilbault
    Affiliations
    Emergency Department, Strasbourg University Hospital, Hautepierre Hospital, 1 Avenue Molière, 67200 Strasbourg, France

    INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), University of Strasbourg, France
    Search for articles by this author

      Keywords

      1. Presentation

      A 32-year-old woman, presented to the Emergency Department (ED) with a 15-day fever, and a sore throat recently associated with a growing abdominal pain. At admission in the ED, the patient had normal vital parameters and her history showed no underlying comorbidities. On physical examination, abdominal tenderness was observed with an important (8/10) left upper quadrant pain associated with a palpable splenomegaly. The rest of the clinical examination was normal except for a mild odynophagia. Six days before the ED admission, the patient had consulted her General Practitioner who prescribed a complete blood test. These laboratory results showed a white blood cell count of 10,65 × 109/L with 56.4% lymphocytes, a normal platelet count and an elevated level of ALAT (150 UI/L) and ASAT (183 UI/L) with a mild inflammatory syndrome (CRP: 39 mg/L). Serologic viral screening was negative for hepatitis B and C viruses, human immunodeficiency virus and cytomegalovirus. However, serological testing detected EBV viral capsid antigen immunoglobulin M (VCA-IgM) antibodies at high titer. These results were compatible with mononucleosis primo-infection. In this context, abdominal CT was performed due to the intense and persistent pain (Fig. 1).
      Fig 1
      Fig. 1Contrast-enhanced abdominal CT scan (transverse view, venous phase): Multiple splenic infarcts appear as peripheral non-enhancing triangular lesions (black arrow heads).

      2. Diagnosis: Spleen infarction due to acute Epstein-Barr virus infection

      Infectious mononucleosis (IM) is commonly caused by Epstein-Barr (EBV), which is characterized by non-specific symptoms like fever, sore throat and cervical lymphadenopathy. In IM, the spleen is usually increased to 3–4 times normal size but splenic complications such as rupture or infarction have been rarely reported, the exact frequency remains uncertain probably due to underdiagnosis [
      • Heo D-H
      • Baek D-Y
      • Oh S-M
      • et al.
      Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection: Splenic Infarction Following Infectious Mononucleosis by EBV Infection.
      ]. Splenic infarction can have a wide range of clinical presentations from asymptomatic (20–30%) to fatal hemorrhage [
      • Heo D-H
      • Baek D-Y
      • Oh S-M
      • et al.
      Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection: Splenic Infarction Following Infectious Mononucleosis by EBV Infection.
      ]. In the acute setting, contrast-enhanced CT represents the gold standard in this pathology, it has much more sensitivity than ultrasonography [
      • Antopolsky M
      • Hiller N
      • Salameh S
      • et al.
      Splenic infarction: 10 years of experience.
      ]. Usually, conservative management and symptomatic treatments are recommended in splenic infarction in IM patients, but a close follow-up is mandatory because infarcts may recur or progress to splenic rupture or other complications (abscess, pseudocyst, hemorrhage). The pathogenesis of splenic infarction during IM is not yet fully understood and several hypotheses have been advanced. Firstly, arterial blood supply may be insufficient (hypoxemia) for the hypercellular spleen during the acute phase of IM. Secondly, the present of a transient hypercoagulable state has been proposed. Anticardiolipin antibodies or other transient pro-thrombotic factors could be detected. Thereby, a thrombophilia screening should be performed in patients with the association splenic infarction and IM. Anticoagulant therapy is not systematic but will only be used in case of permanent hypercoagulable disorders. Finally, an increased level of circulating immune complexes (excess B cell proliferation), promoting leukocyte aggregation and adhesiveness, has also been associated with splenic infarction [
      • Li Y
      • George A
      • Arnaout S
      • et al.
      Splenic Infarction: An Under-recognized Complication of Infectious Mononucleosis?.
      ]. Our patient was admitted for symptomatic treatment (antipyretics, pain management) and was discharged after a week of observation. The spleen size decreased to normal size at the 30-day follow-up (ultrasound).

      Authorship

      Both authors had access to the data and played a role in writing this manuscript. All authors approved the final manuscript.

      Funding

      None.

      Consent

      Authors would like to thank the patient who has given her written consent.

      Declaration of Competing Interest

      There are no relevant conflicts of interest for any of the authors listed.

      References

        • Heo D-H
        • Baek D-Y
        • Oh S-M
        • et al.
        Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection: Splenic Infarction Following Infectious Mononucleosis by EBV Infection.
        J Med Virol. 2017; 89: 332-336
        • Antopolsky M
        • Hiller N
        • Salameh S
        • et al.
        Splenic infarction: 10 years of experience.
        Am J Emerg Med. 2009; 27: 262-265
        • Li Y
        • George A
        • Arnaout S
        • et al.
        Splenic Infarction: An Under-recognized Complication of Infectious Mononucleosis?.
        Open Forum Infect Dis. 2018; 5: ofy041