Authors: Andrea Leal Lopez, MD and Nathanael Bailey, MD.
Year of Publication: 2024
Clinical History
A young female with no significant past medical history presented to the emergency department with complaints of a sore throat for the past 4 days, as well as periumbilical and left lower quadrant abdominal pain with nausea and vomiting for the past 2 days. Upon questioning, the patient denied any recent trauma. Physical examination demonstrated small posterior cervical lymphadenopathy, hypertrophic tonsils, and mild periumbilical and left lower quadrant abdominal tenderness without rebound. Initial laboratory studies demonstrated leukocytosis (23.7 x10E+09/L) with absolute neutrophilia (11.14 x10E+09/L), lymphocytosis (4.03 x10E+09/L), monocytosis (2.13 x10E+09/L), and eosinophilia (0.47 x10E+09/L). Atypical lymphocytes were also identified (25%) on peripheral blood smear (Figure 1). A complete metabolic panel revealed elevated liver enzymes (alkaline phosphatase: 157 IU/L; aspartate aminotransferase [AST]: 110 IU/L; and alanine aminotransferase [ALT]: 191 IU/L). A pregnancy test was negative.
On imaging, CT scan (Figure 2) displayed mild splenomegaly (14.8 cm), a perisplenic hematoma, with possible active bleeding, and prominent retroperitoneal and mesenteric lymph nodes, considered to be reactive appearing.
A respiratory viral panel was negative, and a Monospot test was non-reactive. However, positive Epstein-Barr (EBV) antiviral capsid antigen (VCA) IgM (4.1 AI) and IgG (118 U/mL), as well as EBV DNA PCR were identified. Of note, EBV nuclear antigen (EBNA) IgG was negative.
Given the concern for active splenic bleeding, a splenectomy was performed.
Flow cytometric immunophenotypic studies performed on the spleen showed a predominance of CD8 positive T-cells, with a CD4 to CD8 ratio of 0.1:1. No overtly abnormal lymphoid population was identified.
On gross inspection, the spleen was enlarged (381 grams), measuring 19.5 cm in greatest dimension, and displayed a few hemorrhagic areas with no discrete nodules (Figure 3).
Microscopic evaluation (Figure 4) revealed prominent lymphoid infiltration of the red pulp, with a prominent white pulp, immunoblastic hyperplasia, lymphocytic vasculitis, and areas of hemorrhage.
Figure 4. Prominent white pulp with areas of hemorrhage (A. 2X, H&E). Lymphocytic vasculitis (B. 10X, H&E). Immunoblastic hyperplasia (C. 40X, H&E).
In-situ hybridization stain shows many EBV positive cells (EBER in-situ hybridization, Figure 5).
The patient recovered without any incidents and was discharged shortly after surgery.