CIin.Lab.Haem CASE REPORT 1995, 17,93-94

Thrombocytopenia and spontaneous rupture of the spleen associated with infectious mononucleosis

J.R. MACGOWAN Depurtment of Huernatology, P. MAHENDRA Box 234,

5. AGER Addenbrookes NHS Trust, R.E. MARCUS Hills Roud, Cambridge C B 2 ZQQ, UK

~ ~~

Summary Infectious mononucleosis (IM) normally has a benign, self-limiting course. Throm- bocytopenia and spontaneous rupture of the spleen are two separate complications of the illness. We describe a patient who suffered from both these complications.

infectious mononucleosis, spontaneous rupture of the spleen, thrombocytopenia Keywords

Introduction

A twenty-two-year-old woman presented to Accident and Emergency with a 24 h history of spontaneous bruising, bleeding gums and minor epistaxis. Five days prior to admission she had a sore throat and a generalized maculopapular rash which resolved spontaneously. There was no history of trauma to the abdomen. She had no past history of note and was not on any medication.

On examination she had a widespread petechial rash, predominantly affecting the extremities and soft palate. She had no lymphadenopathy or splenomegaly. A full blood count revealed: Hb 13.1 g/dl, WBC 6.9 x 10’/1, Platelets 2 x 1 ()’/I. Her clotting screen and biochemistry profile were normal. A blood film showed the presence of atypical lym- phocytes and a bone marrow aspirate demonstrated the presence of normal megakaryocytes with no abnormal infiltrates.

The patient was diagnosed as having immune throm- bocytopenia and trealed with 1 mg/kg of prednisolone. Twenty four h after admission she collapsed and was hypo- tensive. She had no abdominal tenderness or peritonism. Erect and supine abdominal x-rays were normal. A repeat Hb was 8.3 g/dl and she was assumed to have suffered an occult gastro-intestinal bleed. She was transfused and commenced on intravenous immunoglobulin (400 mg/kg/ day). Thirty h after admission she developed abdominal tenderness. Despite a three unit transfusion her Hb was 6.5 g/dl and platelet count 27 x 109/l. An urgent CT scan of her abdomen showed a large quantity of free blood within

Accepted for publication 21 October 7 994 Correspondence: P. Mahendra.

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the peritoneal cavity largely obscuring the spleen. A Mono- spot test was positive. She subsequently had positive Epstein-Barr virus (EBV) serology. A diagnosis of spon- taneous rupture of the spleen secondary to infectious mononucleosis (IM) was made and she underwent an emer- gency splenectomy. At operation 7 litres of blood were removed from the abdomen. She made an uneventful recov- ery and three months post splenectomy she remains well with a platelet count of 300 x 10’/1.

Discussion

A mild thrombocytopenia is a relatively common finding in infectious mononucleosis. Carter et ul. reported a series of 57 patients in whom 50% had a platelet count of less than 140 x 1OY/1. However, less than 1% had a platelet count less than 30 x lO’/l (Carter 1964). Though the thrombocytopenia is self-limiting it may take up to nine months for spontaneous remissions to occur and hence treatment as for immune thrombocytopenia with steroids or immunoglobulin is generally recommended for patients with severe thrombocytopenia. Cryan et ul. described five patients with thrombocytopenia and IM who were treated with immunoglobulin and in whom the haemorrhagic symptoms resolved (Cryan et al. 1991).

Splenomegaly occurs in approximately 50% of patients with IM. The congestion of the spleen and intrinsic changes that occur in the splenic parenchyma with weakening of the splenic capsule render it susceptible to rupture even after minor trauma. True spontaneous rupture of the spleen is very rare. After malaria, IM is the next most common cause of true spontaneous rupture of the spleen (Smith &

1. K. MacGowan et al.

Custer 1946). The most frequent cause of death in patients with IM is sudden splenic rupture (Aldrete 1992). Rutkow revicwed 107 cases of splenic rupture associated with IM. Thcy identified only 18 cases of spontaneous splenic rupture. All 18 patients had an uneventful recovery post splenectorny (Rutkow 1978). Abdominal palpation and minor abdominal trauma may precipitate splenic rupture in patients with 1M (Smith (L Custer 1946). The spleen remains susceptible to rupture even after clinical, haema- tological and serological recovery from the illness. It there- fore seems prudent to advise patients to limit strenuous physical activity for 3-0 months following their systemic illness.

To our knowledge there is only one reported case in the literature of thrornbocytopenia and splenic rupture associ- ated with an EBV infection (Smith & Custer 1946). The patient had a platelet count of 18 x 10y/l at diagnosis. Splenic rupture was diagnosed at laparotomy, but the pati- ent died on the 14th day of his illness. The presence of atypical lymphocytes and the histological changes in the spleen and lymph nodes were taken as sufficient evidence of IM.

Thrombocytopenia is a well recognized finding in IM. Spontaneous splenic rupture however is a rare and more serious complication of IM. In patients who are also throm- bocytopenia severe haemorrhage can occur. Patients with severe thrombocytopenia should be hospitalised and care- fully monitored and an urgent CT scan of the abdomen requested if there are abdominal signs, symptoms or unex- plained hypotension.

References

Aldrete J.S. (1992) Spontaneous rupture of the spleen in patients with infectious mononucleosis. Mayo Clinical Proceedings, 67,

Carter R.L. (1964) Platelet levels in infectious munonucleosis.

Cryan E.M., Rowe J.M. &Bloom R.E. (1991) lntravenous gamma- globulin treatment for immune thrombocytopenia associated with infectious mononucleosis. American Journal of Hernutolog&

Rutkow 1.M. (1978) Rupture of the spleen in infectious rnono- nucleosis: a critical review. Archives of Surgery, 113, 718-720.

Smith E.B. C(r Custer K.P. (1946) Rupture of the splccn in infectious mononucleosis. Blood, I , 3 17-3 3 3.

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