Download SPLENOMEGALY

TWIN LAKES,
Lymph nodes, in conjunction with the spleen,
tonsils, adenoids, and Peyer patches, are highly
organized centers of immune cells that filter
antigen from the extracellular fluid
 Lymph node size depends on the person's age, the
location of the lymph node in the body, and
antecedent immunological events

Lymphadenopathy reflects disease involving the
RES
 nodal accumulation of inflammatory cells in
response to an infection in the node
(lymphadenitis)
 Localized lymphadenitis is most often caused by
staphylococci and beta-hemolytic streptococci.

CASE
PRESENTATION
25 year old woman
 persistent dry cough
 fever, NS, weight loss x 3 months
 right cervical lymphadenopathy (2 cm)
 Right supraclavicular node (2 cm)
 no splenomegaly

DIFFERENTIAL DIAGNOSIS

lymphoma
Hodgkin
 non-Hodgkin

lung cancer(bronchogenic carcinoma, metastase)
 other neoplasms: thyroid, mediastinal
 non-neoplastic causes less likely

sarcoid, TB, fungal( histoplasmosis),..
 Inorganic dust disease(Silicosis)

WHAT
NEXT?
Needle aspirate of LN: a few necrotic cells
 Needle biopsy of LN: admixture of B- and Tlymphocytes. A few atypical cells.

WHAT IS HER DIAGNOSIS ?
nodular sclerosis HD
 with bulky mediastinal mass

LYMPHADENOPATHY
Medical hx should reveal the setting in which
lymphadenopathy is occuring
 Sorethroat , cough, fever, night sweat, wt loss,
pain in nodes
 Patient`s age , sex, occupation, exposure to pet,
sexual behaviour, and use of drugs such as
diphenylhydantoin

Physical exam:
 1- extent of LAP( localized or generalized)
 2-size of nodes ,texture,tenderness,inflammation
on it, skin lesion and splenomegaly
 ENT exam in cervical LAP and hx of tobacco use

Site of adenopathy:
 Occipital( infection of scalp)
 Preauricular ( conjunctival infection and cat
scratch disease)
 Neck( usually benign such as URTI , oral and
dental lesion ,IM, or other viral)
 supraclavicular nodes due to lymphomas,other
cancers and infectious processes arising in lung
and retroperitoneal space( and from testis,
ovaries)
 Virchow`s node in left supraclavicular infiltrated
with metastatic cancer from GI
 Nonspecific causes of supraclavicular nodes :TB,
sarcoidosis and toxoplasmosis

Axillary adenopathy due to injuries or infections
of upper extremity but malignant causes are
lymphoma or melanoma and breast cancer
 Inguinal adenopathy usually due to trauma or
infection of the lower extremities and may due to
STDs ( also may be due to lymphoma and
metastatic cancers)

Size:
 < 1 cm by 1cm almost always benign and reactive
 Retrospective analysis results:
*> 2 cm predict for need to Bx
* > 1.5 by 1.5 cm was the best size limit for
distinguish malignant or granulomatous LAP
from other causes

Texture:
 Soft, firm, rubbery, hard, discrete, matted,
tender, movable or fixed.
 Tenderness in inflammatory diseases due to
rapid stretch of capsule
 Also some malignancies ( acute leukemia) may
produce rapid enlargement and pain in node
 In lymphoma :
large,discrete,symmetric,rubbery,firm,mobile and
nontender
 In metastatic cancers: hard,nontender,
nonmovable


Coexistence with splenomegaly in the patient
with LAP implies a systemic illness IM,
lymphoma ,ALL and CLL,SLE,
sarcoidosis,toxoplasmosis, cat-scratch dis.
Nonsuperficial presentation(thoracic or
abdominal) :
 Thoracic may be detected by routine CXR or
during the w/o for superficial adenopathy
 Also may be found because of symptoms such as
cough, wheeze , hoarseness ,dysphagia and
swelling of face,neck and arms
 DDX for mediastinal and hilar adenopathy:
*in youngers :IM ,sarcoidosis
*in endemic :histoplasmosis , TB
*in olders: primary lung cancers, lymphoma,
metastatic cancers, TB,fungal, sarcoidosis


Intraabdominal or retroperitoneal nodes are
usually malignant
LABORATORY INVESTIGATION
CBC ( for leukemia, EBV or CMV mononucleosis,
lymphoma with a leukemic component, immune
cytopenia in dis. such as lupus and pyogenic
infections)
 Serology ( for EBV, CMV, HIV,and other viruses,
Toxoplasmosis, Brucella)
 ANA and ds-DNA ( for lupus)
 CXR
 Other imagings for differentiate benign from
malignancy

Biopsy:
 In a hx and physical exam compatible with
malignancy
 In primary care centers < 5% of LAPs will require
Bx
 If the patient`s hx and ph. exam point to a benign
cause ,careful follow up at 2-4 week interval can
be used
 The patient should be instructed to return for
reevluate if increase in size
 Antibiotic not indicated unless strong evidence
for bacterial infection


Glucocorticoid should not be used because their
lympholytic effect obscures some diagnoses(
lymphoma, leukemia) and they contribute to
delayed healing or activation of underlying
infection –( an exception is the life-threatening
pharyngeal obstruction by enlarged lymphoid
tissue in weldeyer`s ring thas is occasionally seen
in IM)
SPLENOMEGALY
By : Minoosh Sha`bani MD
STRUCTURE
AND
FUNCTION
RES system
 Arises in a series of hillocks
 Accessory spleens in 20% of persons
 NL role:

1-quality control of erythrocytes

2-synthesis of Abs

3-removal of Ab-coated bacteria

& Ab-coated RBC
 An increase in these normal function results in
splenomegaly

Splenic artery, arterioles, some blood goes to
capillaries and then vein and out of the spleen
 But the majority of blood from arteriols to
sinuses and cords, for entering the circulation
blood cell must squizz through slits of cord then
enter to venules and …
 Old and damaged RBCs are retained ,destroyed
and their components recycled
 RBC-inclusion bodies ( parasites), nuclear
residua (Howell-jolly),denaturated Hb (Heins
bodies) are retained and this removal of particles
from within circulating RBCs defined as pitting

 Culling:
circulation
removal of senescent RBCs from the
- consists of the capsule and trabeculae which enclose
the pulp.
- 3 zones of the pulp
a. White pulp – lymph node; contains
lymphocytes, macrophages, and plasma cells in
a reticular network
b. Red pulp – consists of the cord and
sinuses; contains the cellular elements of the
blood
c. Marginal zone – poorly defined vascular
space between pulps; contains sequestered
foreign material and plasma as well as
abnormal cellular elements
Exrtacellular hematopoesis in myelofibrosis,
marrow damage by toxin or radiation and
marrow infiltration by tumors
 The normal spleen contains 1/3 of total plts and a
significant number of merginated neutrophils
The spleen is the major organ of RES .
 Blood cells leave the splenic arterial bed through
afferent arterioles ,which pass through lymphoid
nodules(white pulp) and then terminates in the
cords of Billroth(red pulp) into which the blood
cells are discharged
 The normal slow flow permits selective action on
the blood cells by macrophages

APPROACH TO SPLENOMEGALY
Clinical: (pain- heavy sense)
 Rupture of spleen ( trauma , infiltrative )
Intraperitoneal bleeding,shock and death
-Weight < 250 gr- with age- cephalocaudal
diameter : 13 cm-Usually not palpable
-A palapble spleen does not always equate with
the presence of disease

PHYSICAL EXAM

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Palapation :
Middleton maneuver:(start from LLQ)
Percussion :
Castel : ant. axillary line
Traube: mid. axillary line( 6th rib and
A tympanitic area overlying gastric stomach bubble in
semilunar space that will be displaced downward following
splenomegaly and ....
Nixon : post. axillary line( on a line vertical to...)
We recommend percuss at first if positive...
Reproducibillity with palpation is better
Spleen lies adjacent to the 9th to the 11th
ribs,stomach,colon and left kidney
BIMANUAL PALPATION
SUPINE
DEEP BREATH
BALLOTTEMENT
PALPATION FROM ABOVE - HOOKING
PERCUSSION OF TRAUBE’S
SPACE – SIXTH RIB
SUPERIORLY, MIDAXILLARY
LINE LATERALLY AND LEFT
COSTAL MARGIN
INFERIORLY. NORMALLY THE
PERCUSSION NOTE IS
RESONANT. DULLNESS
IMPLIES SPLENOMEGALY.
NIXON’S METHOD –
PERCUSS MIDWAY ALONG
LEFT COSTAL MARGIN.
NORMALLY DULLNESS
DOES NOT EXTEND
FURTHER THAN 8 CM
ABOVE THE COSTAL
MARGIN.
DDX
1- Hyperplasia :
( RES hyperplasia in spherocytosis or
thalassemia major )
(immune hyperplasia in response to systemic
infections such as
or to immunologic dis. such as
lupus and ITP)
2- passive congestion
due to decreased blood
flow from the spleen that produce portal HTN(cirrhosis,
Budd-Chiari syn. ,CHF)
3-infiltrative dis.of the spleen (lymphoma,
metastatic cancer, Gaucher`s dis.)
-IM
 -AIDS
 -viral hepatitis
 -CMV
 -SBE
 -Bacterial septicemia

-TB
 -Histoplasmosis
 -Malaria
 -Leishmaniasis
 -Congenital syphilis
 -Splenic abscess

The presence of splenomegaly, posterior cervical
adenopathy, axillary adenopathy, and inguinal
adenopathy is most useful in considering the
possibility of infectious mononucleosis, while the
absence of cervical adenopathy and fatigue is
most helpful in dismissing the diagnosis..
 Because the physical examination is quite
insensitive for detecting splenomegaly (between
27 and 58 percent, depending on the examiner’s
index of suspicion), the absence of splenomegaly
should not be used as evidence against the
diagnosis of infectious mononucleosis.

The original serologic test for infectious
mononucleosis, the Paul-Bunnell test, detected
heterophile antibodies by agglutination of sheep
or horse red blood cells.
 Although they are relatively specific, heterophile
antibody tests are somewhat insensitive,
particularly in the first weeks of illness
 VCA-IgG and VCA-IgM tests are useful in
diagnosing patients who have highly suggestive
clinical features but negative heterophile
antibody test results

Because an enlarged spleen is at risk for rupture,
athletes should not compete in contact sports for
a minimum of four weeks after the onset of
symptoms.
 The risk of splenic rupture is estimated at 0.1
percent

WHAT IS THE REASON OF ANEMIA
Decreased Production
 Anemia of chronic
disease
 Adverse drug reaction
 Marrow infiltration
 Parvovirus B19
infection
 Megaloblastic anemia
IN
HIV
Increased Destruction
 Hypersplenism*
 TTP
 GI bleeding
*Hypersplenism due to
portal HTN from hep B or
C
CMV
In most cases, primary CMV infection is
asymptomatic or produces mild flulike symptoms.
 The lymph nodes and spleen may be enlarged
 Some studies have shown that, as a group,
patients infected with CMV have less
hepatomegaly, splenomegaly, and pharyngitis
than those infected with EBV. Patients with
CMV mononucleosis may be older, have a longer
duration of fever, and have less cervical
lymphadenopathy

SBE

Splenic infarction may occur as a result of emboli.
In this case, splenic palpation may be painful and
tender, and a rub may be heard.
SPLENIC ABSCESS
A rare entity( 0.05-0.7%)
 Etiology:
- The most common is hematogenous spread *Infective
endocarditis, a condition associated with systemic
embolization in 22-50% of cases, has a 10-20% incidence of
associated splenic abscess.
-Other infective sources include typhoid, paratyphoid, malaria,
urinary tract infection, pneumonias, osteomyelitis, otitis,
mastoiditis, and pelvic infections
Contiguous spread - This includes direct involvement from a
pancreatic abscess, gastric or colonic perforations, or
subphrenic abscesses.

-Splenic trauma
-Splenic infarction resulting from systemic disorders (see the
image below), such as hemoglobinopathies (especially sickle
cell disease), leukemia, polycythemia, or vasculitis, can
become infected and evolve into splenic abscesses
Microbiology
 Aerobes (in most published cases)Gram-positive
cocci -Streptococcus, Staphylococcus,
Enterococcus(predominant in most reports)
 Gram-negative bacilli -Escherichia coli,
Klebsiella pneumoniae,
Proteus,Pseudomonas species, Salmonella species
(occasionally predominant)
 Anaerobes -Peptostreptococcus, Bacteroides,
Fusobacterium,Clostridium, Propionibacterium
acnes
 Polymicrobial (up to 50% of cases)
 Fungal -Candida

History
 Fever (>90%) can be moderate, continuous,
intermittent, or even absent.
 Abdominal pain (>60%) typically occurs suddenly
 Involvement of the diaphragmatic pleura can
cause shoulder pain
 Physical examination
 Abdominal tenderness (>50%)
 Splenomegaly (< 50%) is less frequently observed,
probably because of early diagnosis resulting
from the widespread use of imaging methods.

Medical Therapy :
-Early supportive care and parenteral broadspectrum antibiotics
 Surgical Therapy :
-Splenectomy has long been considered the
standard treatment of splenic abscess

SPLENECTOMY
Absolute Indications for Splenectomy
1. splenic tumors – echinoccocal cyst
2. metastatic disease
3. splenic abscess
4.hereditary spherocytosis – most
common
hemolytic anemia for which
splenectomy is
indicated
5. bleeding esophageal varices
6. chronic lymphocytic leukemia
7. hairy cell leukemia
8. Chronic myeloid leukemia – more to
ease the
pain
9. Sarcomas
10. trauma
Splenectomy Outcomes
- post-operative appearance of:
a. siderocytes
b. Howell-Jolly bodies
c. leukocytosis
d. increased platelete count
Complications
1. left lower lobe atelectasis – most
common
2. subphrenic hematoma
3. subphrenic abscess – can occur with
placement of a drain
4. pancreatitis – trauma to the tail of the
pancreas
5. deep vein thrombosis – low dose
Massive splenomegaly in :
 -CML( chronic myeloid leukemia)
 -Lymphomas (esp. NHL)
 -HCL
 -PCV
 -Gaucher`s dis.
 -CLL( chronic lymphocytic leukemia)
 -Sarcoidosis
 -Autoimmune hemolytic anemia

Hematologic outcomes:
-leukocytosis and thrombocytosis
But
After 2-3 wks this profile will be normal

Overwhelming Post-Splenectomy Infection (OPSI)
1. lifetime risk of severe infection( the lowest
risk is for trauma and ITP) and overall
6% of total OPSI
2. incidence of 3.2% post-splenectomy
3. loss of the spleen’s ability to filter and
phagocytose bacteria and infected RBC
most common sources of infection
a. Streptococcus pneumoniae –
most common
b. Heamophilus influenzae B
c. meninggococcus
prevention
a.vaccine against
i. pneumoccocus
ii. H. influenzae
iii. meninggococcus
- to be given 14 days before elective
splenectomy
THANK YOU
ANY QUESTION?