PE - Approach to Splenomegaly Flashcards
List the most common causes of splenomegaly to appear in MRCP
1) Hematological malignancy
- divide into myeloproliferative and lymphoproliferative
2) Portal HT
- usually due to cirrhosis
3) Hemolytic anemia
4) Felty syndrome
Outline the clinical features of myeloproliferative disease
1) No stigmata of chronic liver disease
2) Presence of conjunctival pallor
3) No scleral jaundice
4) No evidence of rheumatological disease
5) No lymphadenopathy
6) Excoriations marks suggest pruritus
7) Marked splenomegaly
8) No hepatomegaly, ascites, or peripheral edema
9) No hepatic venous hum
10) No signs of hepatic encephalopathy
anemia + pruritus + marked splenomegaly
Outline the clinical features of lymphoproliferative disease
1) No stigmata of chronic liver disease
2) Presence of conjunctival pallor
3) No scleral jaundice
4) No evidence of rheumatological disease
5) Widespread lymphadenopathy
6) Excoriation marks suggest pruritus
7) Hepatosplenomegaly with mild splenomegaly
8) No ascites or peripheral edema
9) No hepatic venous hum
10) No signs of hepatic encephalopathy
anemia + pruritus + mild splenomegaly + lymphadenopathy + hepatomegaly
Outline the clinical features of Felty syndrome
1) No stigmata of chronic liver disease
2) Presence of conjunctival pallor
3) No scleral jaundice
4) Symmetrical deforming arthropathy in small joints of hands + ulnar deviation + forearm nodules + vasculitic rash (?livedo reticularis)
5) Variable lymphadenopathy
6) No excoriation marks
7) Mild splenomegaly
8) No hepatomegaly, ascites, or peripheral edema
9) No hepatic venous hum
10) No signs of hepatic encephalopathy
anemia + mild splenomegaly + rheumatoid arthritis ± neutropenia (check CBC w/differential)
What would be the most likely diagnosis in a patient w/scleral jaundice + no stigmata of chronic liver disease + splenomegaly?
Jaundice likely resulted from hemolysis in context of hematological malignancy
Cold autoimmune hemolytic anemia is especially associated w/chronic lymphocytic leukemia (CLL)
In patients w/splenomegaly what could cause joint pain?
1) Hyperuricemia in context of hematological malignancy inducing acute gout
2) Felty syndrome which is a triad of seropositive RA + splenomegaly + neutropenia
List all lymph nodes to check if patients present w/hepatosplenomegaly
1) Cervical
2) Supraclavicular
3) Infraclavicular
4) Axillary
5) Epitrochlear
6) Inguinal
Outline the size of a normal and a palpable spleen
Normal spleen = around 12cm
Palpable spleen = more than 15cm
Given that a mildly enlarged spleen will not be palpable what physical examination could screen for mild splenomegaly
Percussion over Traube’s space can detect subtle splenic enlargement; this space is normally occupied by the stomach so it is resonant while fasting; when the spleen enlarges this area becomes dull on percusion
Posterior border = left mid-axillary line/anterior axillary line
Superior border = left 6th rib
Inferior border = left costal margin
Marked splenomegaly without lymphadenopathy
Myeloproliferative disorder
Mild splenomegaly with lymphadenopathy ± hepatomegaly
Lymphoproliferative disorder
List the 5 characteristics of a spleen on physical examination
1) Enlarges along Gardner’s line to the right iliac fossa
2) Unable to get over the mass
3) Dull on percussion
4) Not ballotable
5) Possesses a medial notch
List the causes of splenomegaly by frequency
1) Portal HT
2) Hematological malignancy
3) Infection (e.g. endocarditis, HIV)
4) Congestion or inflammation (e.g. heart failure)
5) Primary splenic disease (e.g. splenic vein thrombosis)
6) Other
List the causes of splenomegaly by spleen size
Massive splenomegaly = crosses midline
1) Chronic myeloid leukemia
2) Myelofibrosis
3) ADIS w/Mycobacterium avium complex
4) Malaria
5) Kala-azar (visceral leishmaniasis)
Moderate splenomegaly = does not cross midline
1) Portal HT
2) Acute/chronic leukemia
3) Lymphoma
4) Thalassemia
5) Glycogen storage disease
Mild splenomegaly
1) Hemolysis (e.g. hemolytic anemia)
2) Infection (e.g. EBV, infective endocarditis)
3) Autoimmune disease (e.g. RA, SLE)
4) Infiltrative conditions (e.g. amyloid, sarcoid)
5) Other myeloproliferative disease (e.g. polycythemia rubra vera)
List conditions that cause isolated splenomegaly
1) Autoimmune diseases
2) Primary splenic diseases (e.g. splenic vein thrombosis, splenic abscess)
Outline the B symptoms and explain its name
1) Fever >38 degrees
2) Weight loss >10% body weight in 6m
3) Night sweats
1/3 qualifies for B symptoms
In the Ann Arbor staging of lymphomas, A represents absence of systemic symptoms while B indicates their presence –> seen in malignancy, infection, or autoimmune conditions
List important relevant history to ask in a patient w/splenomegaly
1) Risk factors for liver disease
2) Hx pancytopenia (bruising for PLT, fatigue and SOB for Hb, infections for WCC)
3) Risk factors for lymphoma (FHx, Hx RT, Hx chemotherapy, immunosuppressants, organ transplant)
4) HIV infection
5) Risk factors for autoimmune disease
6) Risk factors for malaria (travel Hx, prophylaxis)
7) Bone/joint paint (extramedullary hemopoiesis or secondary hyperuricemia)
List investigations to perform in a patient w/splenomegaly
Blood tests
1) CBC w/differential for blasts
2) Blood film for blasts
3) RLFT
4) LDH elevated w/hemolysis, blast cells, lymphoma
5) Beta-2 microgloublin elevated w/multiple myeloma, lymphoma, and amyloidosis
6) Autoimmune profile
7) HIV antibody
8) BCR-ABL t(9;22) mRNA detection
- CML diagnosis + CML monitoring disease activity
Imaging
1) USG spleen
2) Axial CT chest, abdomen, pelvis for lymphadenopathy
3) PET for non-Hodgkin lymphoma
Biopsies
1) Lymph node biopsy
2) Bone marrow biopsy
- myeloid/lymphoid disorders
- lipid storage disease
- mycobacterial infection
Outline the features of Felty syndrome
Triad of
1) Rheumatoid arthritis
2) Splenmegaly
3) Neutropenia
Explain the clinical significance of blast crisis
1) Phase in hematological malignancy similar to acute leukemia
2) Characterized by presence of blast cells in
1. Bone marrow
2. Peripheral blood
3. Skin
4. Tissue
List the causes of hyposplenism
1) Splenic infarction (e.g. sickle cell disease, vasculitis)
2) Splenic artery thrombosis
3) Infiltrative conditions (e.g. amyloid, sarcoid)
4) Celiac disease
5) Autoimmune disease
Outline essential advice that must be given to patients w/hyposplenism or splenectomy
1) Vaccinations for encapsulated organisms w/repeat vaccinations every 5-10y –> Streptococccus pneumoniae, Haemophilus influenzae type B, Meningococcal C
2) Prophylactic antibiotics –> phenoxymethylpenicillin (penicillin V) or erythromycin for at least 2y
3) Attend AED immediately if patient becomes ill w/infection for administration of parenteral antibiotics
4) Carry an information card or wear a medic alert bracelet to inform healthcare providers of hyposplenism
