morning report

4 year old girl

severe abdominal pain for 2 days seen in ER and thought to have viral gastroenteritis pain became more severe fever to 101 F pain localized to umblilicus went back to the ER....

ROS
ROS Positives:
poor PO, dehydration, fevers, fatigue, paler than normal, underlying constipation and given enema for no stool for 5 days. no vomiting

ROS Negatives:
vomiting, diarrhea, history of trauma, rash, bruising, petechiae, bloody stool.

PMH, SH, FMH

PMH: -ASD/VSD repair -spleenomegaly noted by PCP in December/January. Had CMV (IgG elevarted) EBV (neg) and blood smear done at the at time (mostly likely reactive viral process). -history of mild anemia -T and a. FMH: mom with spleenectomy at age 20 SH: noncontributory, no sick contacts

Physical Exam
Weight 17.1 kg, BP 88/54, HR 120, RR 28, T 37.2. GEN: Pale appearing lying in bed asleep in no distress. HEENT: Sclerae anicteric. Pupils equal and reactive. EOMI. OP clear without erythema. Neck supple without lymphadenopathy. CV: Mild tachycardia with 2/6 systolic murmur with fixed split S2 heard best over mid-sternum. Capillary refill < 2 seconds. 2+ dorsalis pedis pulses. Warm and well perfused. PULM: Normal respiratory effort. Lungs clear bilaterally. ABD: soft and with mild distention. Liver is at RCM. Spleen palpable 4-5 cm below LCM. Diffuse tenderness to palpation most severe at umbilus and left side. Mild guarding. No rebound or peritoneal signs. No overlying bruising. + BS LYMPH: NO LAD EXT: Warm and well perfused. No jaundice, petechiae or bruising. SKIN: No rashes. Pale.

CT Scan
1.

Findings strongly suggest global splenic infarct, with only capsular enhancement of the spleen. The etiology is unclear, as location of the spleen is normal, without findings to suggest a wandering spleen or findings to suggest torsion of the spleen. There are no findings to suggest trauma in the abdomen.

Differential
ID Infective endocarditis EBV, CMV, etc Malaria HIV Onc Myleoproliferative disorders Myleodysplastic syndromes Leukemias/lymphomas Trauma Anatomic (wandering spleen) Large spleens syndromes (eg Gaucher's disease)

Heme

GI

thromboembolic events (cardioembolic, hypercoaguable states) hemoglobinopathy (sickle cell, spherocytosis)

pancreatitis

Labs
CBC: WBC = 14; differential 73% Neutrophils, 0% Band forms, 15% Lymphocytes, 12% Monocytes, 0% Eosinophils; Hgb = 10.1, Hematocrit = 31, Platelet = 94. MCV 82.6, MCHC 32.7 Complete Metabolic Panel: Na = 133, K = 4.7, Cl = 96, CO2 = 24, BUN = 13, Cr = 0.44, Glucose = 105, Ca = 9.3, Protein = 8, Albumin = 4.2, Bilirubin = 1.9, Alk. Phos. = 165, ALT = 13, AST = 68 Amylase/lipase normal Uric acid: 7.2 LDH: 1429 PT: 17.4 INR: 1.5 PTT: 34 UA 2+ ketones, 1+ hgb; otherwise normal EBV negative

To the OR with Dr. Meyers...

When [Dr. Meyers] reviewed the CT scan, [she] was actually somewhat struck by the dilation of what appeared to be the hilar vessels and wondered if this could represent some kind of outflow obstruction, raising the possibility of volvulus. So she took the child to the OR where... The spleen was indeed infarcted. There were, however, some tiny scattered islands of perfusion. When [she] placed the spleen on upward traction, [she] noted about 720 degree complete twist of the splenic pedicle with no fixation of the spleen to the retroperitoneum. .....WANDERING SPLEEN

Common Features of Splenic Infarcts

Left-sided abdominal pain (48%) Abdominal pain absent (16%) Fever >38C (36%) Nausea or vomiting (32%) Splenomegaly (32%) Elevated LDH (71%) White blood cell count >12 (56%)

Wandering Spleen
Acquired laxity or congenital underdevelopment or absence of the primary ligamentous attachments of the spleen Increased risk of splenic torsion and infarction Most commong in children congenital diaphragmatic hernia prune-belly syndrome renal agenesis gastric volvulus 2/3 of patients require splenectomy Early diagnosis allows for splenopexy and preservation of splenic function

Post-Splenectomy Care
Increased risk of infections, esp younger children Vaccines
Ensure have had PCV 13 Age >2 give PCV 23 at least 8 weeks after PCV 13 series finished, second dose 5 years later Age >2 give Menectra PPX: children <5 for at least one year postsplenectomy Penicillin 125 mg BID <age 5 Penicillin 250 mg BID >age 5