Palpable Spleen
Differential Overview
Infection
❑ Infectious mononucleosis
❑ Viral hepatitis
❑ HIV infection
❑ Bacterial endocarditis
❑ Falciparum malaria
❑ Typhoid fever
❑ Brucellosis
❑ Schistosomiasis
Immunologic Disorders
❑ Immune hemolytic anemia
❑ Rheumatoid arthritis
Hematologic Disorders
❑ Thalassemia minor
❑ Lymphoma
❑ Chronic myelogenous leukemia
❑ Polycythemia vera
Congestive
❑ Congestive heart failure
❑ Portal hypertension
Infiltrative
❑ Sarcoidosis
❑ Lysosome storage diseases
Other
❑ Splenic trauma
Diagnostic Approach
Palpation for splenic enlargement should be done with the patient supine, the examiner’s left hand supporting the posterior rib cage and the right hand feeling in the left upper quadrant for the spleen to tap the fingertips on inspiration. A palpable spleen is usually more than 50% enlarged (over 300 gm). Percussion is performed at the lowest rib margin in the left anterior axillary line (Castell space), listening and feeling for dullness in either inspiration or exhalation.
A palpable spleen may be found in 3% of young adults. If there is an
otherwise normal history and physical examination and if the CBC and chest x-ray are normal, the patient is without an increased risk of having/developing a systemic disease. In older adults, an underlying condition can usually be found on investigation.
Massive splenomegaly (down to the right iliac crest) may be found in non-Hodgkin lymphoma, chronic lymphocytic leukemia, chronic myelogenous leukemia, myelofibrosis with myeloid metalpasia, hairy cell leukemia, polycythemia vera, autoimmune hemolytic anemia, Gaucher, and chronic malaria.
Fever, peripheral adenopathy, and splenomegaly suggest infectious mononucleosis, Hodgkin lymphoma, sarcoidosis, serum sickness, HIV, or systemic lupus. In acute infections, the spleen will be soft and tender on palpation. In chronic and infiltrative diseases, the spleen will be firm and nontender.
Left upper quadrant masses that can be mistaken for an enlarged spleen include perinephric abscess, feces, and tumors of the kidney, adrenal gland, splenic flexure, or pancreas. Renal masses will usually retain the medial notch and will be more posterior. Colon masses will not have a well-defined edge. Pancreatic masses will be more medial.
Clinical Findings
Infectious mononucleosis It is characterized by acute onset of fever, sore throat with exudative tonsillitis, marked fatigue, posterior cervical adenopathy, and splenic enlargement in a young adult.
Viral hepatitis A flu-like prodrome with fever, malaise, arthralgias, and urticarial rash will be followed by jaundice with a tender liver. Splenomegaly with cervical adenopathy may occur in as many as 20% of cases.
HIV infection Mild splenomegaly may be part of the generalized lymphadenopathy of early symptomatic disease or a result of opportunistic infection.
Bacterial endocarditis Splenomegaly occurs in 30%, coincident with peripheral petechiae (seen as splinter hemorrhages, Roth spots, or conjunctival petechiae). The underlying infection is characterized by fever and murmur, especially a new or changed murmur.
Falciparum malaria On removal of damaged red cells, the spleen will enlarge, proportionate to the development of anemia. Other clues to the diagnosis are travel to an endemic area, and high, spiking fever with rigors, with the patient relatively well between paroxysms.
Typhoid fever The classic presentation is a stepwise increase in fever to greater than 40˚C with relative bradycardia. The fever can persist for weeks. Rose spots, pale red blanching macules on the trunk, can be seen during the first week. Hepatosplenomegaly is present in most patients.
Brucellosis Symptoms are nonspecific, with fever, malaise, and weight loss in a person who has been in contact with cattle. Splenomegaly may occur in 20% and may be the only clue to the diagnosis.
Schistosomiasis Splenomegaly occurs as a late complication, the result of hepatic fibrosis causing portal hypertension. The patient will have a history of geographic exposure and other stigmata of chronic liver disease.
Immune hemolytic anemia The clinical presentation is usually one of anemia, with lightheadedness, palpitations, and lemon-yellow pallor (caused by anemia combined with hyperbilirubinemia).
Rheumatoid arthritis Felty syndrome, with splenomegaly, occurs in the setting of chronic rheumatoid arthritis. This finding is associated with neutropenia.
Thalassemia minor Mild anemia and icterus may be present. Approximately 20% have a palpable spleen.
Lymphoma Splenomegaly is a common finding and may be prominent. One or more firm lymph nodes greater than 2 cm in diameter secures the diagnosis. B symptoms of fever, weight loss, and night sweats are more common in patients with Hodgkin disease.
Chronic myelogenous leukemia Presenting symptoms relate to hypermetabolism (weight loss, fever, or fatigue) or to left upper quadrant discomfort from the splenomegaly itself. The spleen may become greatly enlarged.
Polycythemia vera Splenomegaly is present in 75% and is a key finding in differentiating primary from secondary polycythemia. Other findings include plethora or dusky cyanosis, blurred vision with retinal venous engorgement, and severe pruritus aggravated by a warm bath.
Congestive heart failure Congestive hepatosplenomegaly occurs in patients with advanced right heart failure. Concomitant findings of jugular venous distension with positive hepatojugular reflux and peripheral edema are found.
Portal hypertension Cirrhosis is the most common cause, but hepatic vein thrombosis can also produce the same result. Splenomegaly is congestive, and it co-occurs with ascites and visible distension of the veins on the abdominal wall (caput medusa). As a general rule, splenic enlargement in portal hypertension occurs with an intrahepatic cause. Extrahepatic causes, such as portal vein thrombosis or compression from pancreatic cancer, do not usually produce splenomegaly.
Sarcoidosis Constitutional symptoms such as fever, fatigue, and weight loss are common but nonspecific. Lung involvement is marked by exertional dyspnea and dry rales. Lymphadenopathy, Bell palsy, iritis, parotitis, or skin lesions such as erythema nodosum, waxy plaques, or indurated, swollen, blue-purple facial lesions of lupus pernio can provide diagnostic clues. Splenomegaly occurs in 10%.
Lysosome storage diseases Although hepatosplenomegaly is common in lysosomal storage diseases, the diagnosis is usually well-established. An exception is Gaucher disease, which can present in adulthood with splenomegaly and/or pathological fractures, without neurologic symptoms.
Splenic trauma Blunt trauma to the left upper quadrant with persistent pain should raise the possibility of intracapsular splenic hemorrhage. Palpation of the spleen in this circumstance is dangerous.
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Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Splenomegaly (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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