Abstract Infectious mononucleosis caused by the Epstein-Barr virus (EBV) is typically a self-limiting illness; however, it can occasionally lead to severe and potentially fatal complications such as atraumatic splenic rupture (ASR). We report a case of spontaneous ASR in a 53-year-old female with confirmed EBV infection. Although splenic rupture is an uncommon manifestation of EBV infection, it carries significant morbidity and mortality. This case underscores the importance of maintaining a high index of suspicion for splenic rupture in patients with acute EBV infection who present with abdominal pain, tenderness, or signs of hemodynamic instability. Prompt recognition and intervention are essential to prevent fatal outcomes. Case Presentation A 53-year-old woman presented to the emergency department with right upper quadrant and epigastric pain radiating to the back, accompanied by nausea and diarrhea for several days. She had recently experienced upper respiratory symptoms and was diagnosed with infectious mononucleosis with a positive Monospot test. She was admitted with a working diagnosis of acute gastroenteritis. Initial CT imaging of the abdomen and pelvis revealed splenomegaly and enlarged right hilar, mediastinal, and right inguinal lymph nodes. On hospital day two, the patient acutely decompensated with hypotension and unresponsiveness. A point-of-care ultrasound (POCUS) revealed free fluid in the abdomen. The patient suffered a brief cardiac arrest and was resuscitated with a massive transfusion protocol. Hemoglobin dropped from 13 upon admission to 6.8, corresponding with the diagnosis of intrabdominal hemorrhage. The patient underwent emergent exploratory laparotomy, demonstrating a grade V splenic rupture requiring a splenectomy. The abdomen was closed the next day following a reexploration. Postoperative course was uncomplicated, and the patient was discharged home with follow-up. Histopathology was negative for malignancy. Conclusion This case highlights the importance of recognizing splenic rupture as a potential complication of EBV infection, even when patients present with atypical or nonspecific features. Although spontaneous ASR is extremely rare, EBV-associated infectious mononucleosis remains the most frequently reported cause. The condition is classically described in young adult males, particularly those engaged in contact sports, where increased intra-abdominal pressure or minor trauma can exacerbate splenic vulnerability. Our case is unique in presentation in terms of age, gender, and risk factors for an EBV-associated spontaneous splenic rupture. This case emphasizes the varied presentation of a common disease and underlines the importance of maintaining a high degree of suspicion for rare yet life-threatening complications, and the use of POCUS in setting of acute decompensation, optimizing outcomes. This abstract is funded by: None
Patel et al. (Fri,) studied this question.