Chronic Abdominal Pain from Disseminated Splenosis.

Chronic Abdominal Pain from Disseminated Splenosis Michael A. Santos, MD1,2 1WellSpan Good Samaritan Hospital, Lebanon, PA, USA; 2Penn State Milton S Hershey Medical Center, Hershey, PA, USA. KEY WORDS: clinical image; abdominal mass; disseminated splenosis; nuclear scintigraphy. J Gen Intern Med 33(6):976–7 DOI: 10.1007/s11606-018-4414-x © Society of General Internal Medicine 2018 A 60-year-old woman presented with several years of dull left upper quadrant, mid-epigastric, and right flank pain. Abdominal CT showed multiple soft tissue densities of unclear etiology. She reported having a post-traumatic splenectomy in the 1960s. A technetium-99m-labeled heat-damaged RBC scan (Tc 99m-dRBC) demonstrated radiotracer uptake in the left upper quadrant, posterior to the right kidney, and along the right diaphragm, confirming ectopic splenic deposits (Fig. 1). Disseminated splenosis (DS) is a benign condition caused by metastatic deposits of splenic tissue following trauma or surgery. DS is usually asymptomatic and diagnosed inciden- tally by ultrasound or computed tomography, but can cause site-specific discomfort mimicking endometriosis or peritoneal metastases. 1 Other reported complications include gastrointes- tinal bleeding, bowel obstruction, and hydronephrosis. 2 Nu- clear scintigraphy with Tc99m-dRBC localizes ectopic splenic tissue based on the increased uptake of damaged erythrocytes within the reticuloendothelial system. 3, 4 In the setting of previous splenic trauma, this noninvasive technique is a sen- sitive and specific tool to establish the diagnosis, potentially avoiding invasive tissue sampling or diagnostic laparoscopy. 5 Patients with DS may retain partial immunoprotection from encapsulated organisms,6 but no studies have shown an opti- mal approach to assessing residual splenic function.7 Corresponding Author: Michael A. Santos, MD; WellSpan Good Samaritan Hospital, Lebanon, P A, USA Compliance with ethical standards: Prior presentations: None. Conflict of Interest: The author declares that he does not have a conflict of interest. REFERENCES 1. Short NJ, Hayes TG, Bhargava P . Intra-abdominal splenosis mimicking metastatic cancer. Am J Med Sci 2011;341:246–9. 2. Connell NT, Brunner AM, Kerr CA, Schiffman FJ. Splenosis and sepsis: the born-again spleen provides poor protection. Virulence 2011;2:4–11. 3. Schiff RG, Leonidas J, Shende A, Lanzkowski P . The noninvasive diagnosis of intrathoracic splenosis using technetium-99m heat-damaged red blood cells. Clin Nucl Med 1987;12:785–7. 4. Horger M, Eschmann SM, Lengerke C, Claussen CD, Pfannenberg C, Bares R. Improved detection of splenosis in patients with haematological disorders: the role of combined transmission-emission tomography. Eur J Nucl Med Mol Imaging 2003;30:316–9. 5. Lake ST , Johnson PT , Kawamoto S, Hruban RH, Fishman EK. CT of splenosis: patterns and pitfalls. AJR Am J Roentgenol 2012;199:W686–93. 6. Pearson HA, Johnston D, Smith KA, Touloukian RJ. The born-again spleen. Return of splenic function after splenectomy for trauma. N Engl J Med 1978;298:1389–92. 7. de Porto AP , Lammers AJ, Bennink RJ, ten Berge IJ, Speelman P , Hoekstra JB. Assessment of splenic function. Eur J Clin Microbiol Infect Dis 2010;29:1465–73. Published online April 2, 2018 976 Fig. 1 Maximum intensity projection (MIP) anterior and posterior images of Tc 99m scan showing increased radiotracer uptake in three separate splenic tissue deposits in the left upper quadrant measuring 2.3, 2, and 1.5 cm (red arrows), a 1.7 cm subphrenic deposit beneath the right diaphragm (blue star), and a 3 cm deposit posterior to the right kidney (green arrowhead), all correlating with her sites of discomfort. 977Santos: Chronic Abdominal Pain from Disseminated SplenosisJGIM