Management of Epstein-Barr Virus Positive Splenomegaly with Areas of Infarction
The management of EBV-positive splenomegaly with areas of infarction should primarily involve conservative supportive care without anticoagulation, with surgical intervention reserved only for specific complications such as splenic rupture, abscess formation, or hemorrhagic shock. 1, 2
Diagnosis and Assessment
- CT scan with intravenous contrast is the gold standard for diagnosing splenic infarction, with sensitivity and specificity of 90-95%, showing peripheral low-density, wedge-shaped areas 1
- MRI offers similar diagnostic accuracy to CT for splenic infarction, while ultrasonography is less sensitive 1
- EBV infection should be confirmed through serological testing (EBV IgM, IgG) and/or PCR testing of blood samples 3, 2
- Monitor for signs of complications including persistent fever, recurrent bacteremia, or other signs of sepsis which may indicate progression to splenic abscess 1
Initial Management
- Conservative supportive care is the mainstay of treatment for uncomplicated EBV-associated splenic infarction 2, 4
- Avoid unnecessary anticoagulation as most cases of EBV-related splenic infarction resolve with supportive care alone 2, 5
- Monitor EBV viral load by quantitative PCR to assess disease activity and response to treatment 3
- Pain management with appropriate analgesics for abdominal discomfort 4
- Ensure adequate hydration and rest 4
Monitoring for Complications
- Regular clinical assessment for signs of splenic rupture or hemorrhage, which is a rare but serious complication 1, 6
- Serial imaging (ultrasound or CT) to monitor the evolution of splenic infarcts and splenomegaly 1
- Watch for development of pseudocyst formation as a potential complication 1
- Monitor for signs of secondary bacterial infection or abscess formation 1
Indications for Surgical Intervention
- Splenectomy is indicated for development of splenic abscess 1
- Surgical intervention is necessary for splenic rupture with hemorrhagic shock or failed non-operative management with continued hemodynamic instability 1, 3
- Consider intervention for persistent symptoms and complications such as hemorrhage, splenic abscesses, or pseudocyst formation 3
Special Considerations
- In patients with underlying hematological conditions, cytoreductive therapy for the primary disease can lead to successful regression of splenic infarction without surgical intervention 3
- For patients with post-transplant EBV infections, reduction of immunosuppression should be considered when possible 3
- In transplant patients with high EBV viral loads, rituximab (375 mg/m²) may be considered as pre-emptive therapy to prevent progression to post-transplant lymphoproliferative disorder (PTLD) 3
Follow-up
- Continue monitoring until resolution of symptoms and radiographic improvement of splenic lesions 1
- Differentiation between uncomplicated infarction and abscess can be made based on clinical and radiographic improvement with appropriate therapy 1
- Most patients with EBV-associated splenic infarction recover completely with supportive care alone 2
Pitfalls and Caveats
- Splenic infarction due to EBV is likely underdiagnosed and may present with atypical symptoms including referred pain to the neck and shoulder (Kehr's sign) 7, 6
- Avoid unnecessary investigations or treatments as awareness of the association between EBV and splenic infarction can help guide appropriate management 2
- The presentation of splenic injury can vary from mild abdominal pain to hemodynamic instability, requiring a high index of suspicion 6
- Neurological complications such as aseptic meningitis can rarely co-occur with splenic infarction in EBV infection 2