SPLENOMEGALY
The patient is lying on the table and has a palpable mass in the left
upper quadrant. The mass has a hard, smooth surface with a notch on the edge
and descends on inspiration. The patient has an enlarged spleen. What can be
done about it? What is causing it?
The key word is histology. Think about the histologic components:
parenchyma, supporting tissue, arteries, veins, and a capsule. What is the
parenchyma? It is nothing more than the components of the blood: red cells,
white cells, lymph tissue, and platelets. Now it is possible to form a
differential. Increased numbers of red cells recall polycythemia; increased
numbers of white cells recall leukemia and infection. Increased lymph tissue
suggests Hodgkin lymphoma, whereas increased supporting tissue indicates
reticuloendotheliosis and acromegaly. Increased vein size occurs in
obstruction of the portal vein as in cirrhosis, thrombosis of the portal
vein, and CHF. If the artery has a local increase in size, an aneurysm
forms, compressing the splenic veins.
A differential is at hand, but it is still incomplete. Now think of
physiology. The spleen is a reserve for blood storage. It is also
able to form red cells and other components of the blood when the bone
marrow is atrophied, as in extramedullary erythropoiesis. More important, it
is involved in the destruction of old or damaged red cells and platelets.
Finally, it hypertrophies to fight infection just like the lymph glands.
Extramedullary erythropoiesis recalls the splenomegaly of aplastic anemia
and myeloid metaplasia, just as destruction or sequestration of cells brings
to mind the splenomegaly of hemolytic anemias (e.g., hereditary
spherocytosis, malaria, and lupus erythematosus) and thrombocytopenic
purpura. The hypertrophy to fight infection or diffuse inflammation of the
body should suggest the splenomegaly of bacterial endocarditis, kala-azar,
infectious mononucleosis, miliary tuberculosis, and rheumatoid arthritis.
Almost anything that causes generalized lymphadenopathy can cause
splenomegaly.
Only one category of splenomegaly is not brought to mind by this approach,
but it is easily remembered because it is an exception—infiltration of
inert material. Thus, in gargoylism there is a foreign mucopolysaccharide in
the spleen. Numerous mucopolysaccharidoses are now described in the
literature. There is a buildup of lipids in the reticuloendotheliosis of
Gaucher disease, Niemann–Pick disease, and Hand–Schüller–Christian
disease, but these are intracellular. Amyloid may infiltrate the spleen.
Metastatic carcinoma of the spleen is rare.
Table 52 summarizes the above discussion and gives additional
causes of splenomegaly to consider in the differential. One final diagnosis
to consider is traumatic splenomegaly.
Approach to the Diagnosis
How does one go about pinning down the diagnosis? There are several
clinical clues. One looks during the physical examination for jaundice,
lymphadenopathy, a rash, sore throat, hepatomegaly, and a positive
Rumpel–Leede test. The combination of symptoms and signs will eliminate
certain causes and make others more plausible. For example, splenomegaly
with jaundice but no hepatomegaly suggests hemolytic anemia. The size of the
spleen is also an important differential feature. If the spleen is very
large, it should suggest myeloid metaplasia, chronic myelogenous leukemia,
Gaucher disease, and kala-azar.
The laboratory is the principal aid from this point on. Smears for red cell
morphology, malaria, and other parasites are invaluable. Blood cultures and
a lymph node and bone biopsy may be useful. If a specific disease is
strongly suspected, consult Appendix A for
appropriate tests.
SPLENOMEGALY
|
| Increased | | Increased | | |
|
| Production | Neoplasia | Destruction | Obstruction | Infiltration |
|
|
|
Red Cells |
Aplastic anemia Myelophthisic anemia |
Polycythemia |
Hemolytic anemia Lupus erythematosus
Pernicious anemia |
|
White Cells |
Myeloid metaplasia Infection |
Leukemia |
Agranulocytosis |
|
Platelets |
|
|
Idiopathic thrombocytopenic purpura |
|
Lymph Tissue |
Infectious mononucleosis |
Hodgkin lymphoma Lymphangioma |
Supporting Tissue |
|
Metastatic carcinoma (rare) |
Lupus erythematosus Collagen disease |
|
Hemochromatosis Reticuloendotheliosis Hurler
disease
Amyloidosis Sarcoidosis |
|
Arteries |
|
|
|
Embolism Aneurysm | |
|
Veins |
|
Hemangioma |
|
Congestive heart failure Cirrhosis
Thrombosis Banti
disease Carcinoma of the tail of the pancreas |
|
Other Useful Tests
-
CBC and differential (anemia, leukemia)
- Blood smear for morphology (anemia)
- Reticulocyte count (hemolytic anemia)
- Platelet count and clot retraction (thrombocytopenia)
- Radioactive chromium–tagged red cell (hemolytic anemia)
- Serum haptoglobins (hemolytic anemia)
- Bone marrow examination (aplastic anemia)
- Blood cultures (SBE)
- Febrile agglutinins (infectious disease)
- Heterophil antibody titer (infectious mononucleosis)
- Brucellin agglutinins (brucellosis)
- Blood smear for parasites (malaria, trypanosomiasis)
- Liver function studies (cirrhosis, Banti syndrome)
- Rheumatoid arthritis test (Felty syndrome)
- ANA test (collagen disease)
- Serum protein electrophoresis (lymphoma, collagen disease)
- Hemoglobin electrophoresis (hemolytic anemia)
- Esophagram (esophageal varices) (portal cirrhosis)
- X-ray of long bones (Gaucher disease, metastasis)
- Flat plate of abdomen for spleen size (splenomegaly)
- Lymph node biopsy (Hodgkin lymphoma)
- Liver biopsy (cirrhosis)
- Splenic aspirate (lymphoma, leukemia)
- Splenoportogram and splenic pulp pressure (portal cirrhosis)
SPUTUM
|
| V | I | N | D |
|
| Vascular | Inflammatory | Neoplasm | Degenerative and |
|
| | | | Deficiency |
|
Larynx and Trachea |
|
Laryngotracheitis Viral or bacterial infection
Diphtheria |
|
Bronchi |
|
Bronchitis, acute and chronic |
Carcinoma of the lung Bronchial adenoma |
| |
| |
|
Alveoli |
Pulmonary infarct (rarely) Congestive heart failure |
Pneumonia (viral, bacterial) Tuberculosis Fungus Parasite Rickettsia |
Alveolar carcinoma Metastasis |
Pulmonary emphysema Pulmonary fibrosis |
|
Capillaries |
|
|
Hemangioma |
| |
| |
|
- Purified protein derivative (PPD) test, intermediate, and skin
tests for various fungi (see Table 36)
- Skin biopsy (hemochromatosis)
- Muscle biopsy (collagen disease, trichinosis)
- Diagnostic ultrasound (cyst, splenic aneurysm)
- CT scan (malignancy)
- Liver–spleen scan (splenomegaly)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
More About Causes of Swollen spleen
» Next page: Splenomegaly (The 5-Minute Pediatric Consult)
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