From the Guidelines
I strongly recommend an ultrasound of the spleen for this 10-year-old patient with mononucleosis, given the left upper quadrant pain, which may indicate splenomegaly or other splenic complications, as suggested by 1. The patient's presentation with left upper quadrant pain raises concern for possible splenic enlargement (splenomegaly), which is a common complication of mononucleosis.
- Splenomegaly increases the risk of splenic rupture, a rare but serious complication that requires immediate medical attention.
- The neck pain could represent significant lymphadenopathy, another hallmark of mono. An ultrasound of the spleen would provide valuable information about the extent of splenomegaly, guiding management decisions.
- If significant splenomegaly is detected, the patient should avoid contact sports and strenuous physical activity for at least 3-4 weeks or until follow-up imaging confirms resolution. Treatment remains supportive with acetaminophen or ibuprofen for pain and fever, adequate hydration, and rest, as there is no specific antiviral treatment for mononucleosis. Parents should be educated about warning signs of splenic rupture including sudden, severe abdominal pain, left shoulder pain, or signs of internal bleeding, which would require immediate emergency evaluation, as highlighted in 1. While the evidence from 1 discusses the diagnosis and management of splenic abscess, a complication more commonly associated with infective endocarditis, it emphasizes the importance of imaging in diagnosing splenic complications, further supporting the use of ultrasound in this context. However, given the clinical context of mononucleosis, the primary concern is splenomegaly and potential rupture rather than abscess formation. Thus, focusing on splenic ultrasound as the initial diagnostic step is prudent, considering the higher relevance of splenomegaly in mononucleosis, as indirectly supported by the principles outlined in 1.
From the Research
Clinical Presentation and Diagnosis
- The patient, a 10-year-old with mononucleosis and elevated antibodies, presents with neck and left upper quadrant (LUQ) pain, which are symptoms that can be associated with splenic rupture, a rare but potentially fatal complication of infectious mononucleosis 2, 3, 4, 5.
- The occurrence of LUQ pain in a patient with a recent diagnosis of infectious mononucleosis should always be investigated with an urgent abdominal ultrasound scan or CT, especially when associated with pain referred to the left shoulder (Kehr's sign), peritoneal irritation, and haemodynamic instability 2.
- Splenic rupture in infectious mononucleosis often presents as left hypochondrial pain, and its occurrence should be considered whenever abdominal pain occurs, even if the patient does not recall any specific traumatic injury 3, 4.
Imaging and Management
- Radiologic evaluation by ultrasonography and computed tomography is indicated for appropriate management of suspected splenic rupture in patients with infectious mononucleosis 2, 3, 5.
- An ultrasound of the spleen, rather than the soft tissue neck and LUQ, would be more appropriate to investigate the possibility of splenic rupture or laceration, given the patient's symptoms and diagnosis of mononucleosis 2, 3, 4, 5.
- Non-operative management can be successful in hemodynamically stable patients with subcapsular hematoma without overt rupture of the capsule, but splenectomy may be necessary in cases of splenic rupture with active bleeding or hemodynamic instability 3.
Complications and Prognosis
- Spontaneous splenic rupture occurs in 0.1 to 0.5% of patients with infectious mononucleosis and is potentially life-threatening, making prompt diagnosis and management essential to minimize complications 2, 3, 6.
- The prognosis is favorable when diagnosis is made on time and correct treatment is started immediately, but avoiding exposure to EBV is almost impossible, and the development of an effective EBV vaccine is necessary to prevent EBV infection and infectious mononucleosis 3, 6.