(908) Atraumatic Splenic Rupture Presenting as Cardiac Arrest From Hemorrhagic Shock in an Adolescent

Introduction: Atraumatic splenic rupture is a rare complication of Epstein-Barr virus (EBV), commonly presenting as abdominal and left shoulder pain. Patients can present in hemorrhagic shock from traumatic splenic rupture. This is a case of an adolescent with acute EBV and atraumatic splenic rupture presenting as cardiac arrest from hemorrhagic shock.

Description: A previously healthy seventeen-year-old girl presented with vomiting and abdominal pain, diagnosed with Streptococcus pharyngitis with a negative Monospot. Four days later, she collapsed at home and progressed to cardiac arrest twice with return of spontaneous circulation (ROSC) after CPR. Initial FAST ultrasound at the outside ED was reportedly negative. She was transferred to our PICU with initial labs of pH 6.6, hemoglobin 3.8mg/dL, INR 3.3, and lactate 24 mmol/L. Bedside ultrasound showed large-volume ascites, leading to Massive Transfusion Protocol activation. Hemodynamic instability led to cardiac arrest then ROSC, requiring emergent bedside exploratory laparotomy. She was hemorrhaging from a grade V splenic injury requiring splenectomy. Lactic acidosis, disseminated intravascular coagulation, hemorrhagic anemia and shock persisted despite resuscitation efforts. Given concerns for ongoing bleeding, repeat exploratory laparotomy six hours later found oozing of two splenic vein branches. Despite replacing her entire blood volume, multi-organ failure and multiple cardiac arrests, she stabilized after transfusion of 111 units of blood products including 47 units of pRBCs in fourteen hours. Labs confirmed EBV, likely the etiology of atraumatic splenic rupture. She survived to discharge five weeks later without neurologic sequelae, requiring intermittent hemodialysis for renal failure.

Discussion: Infectious mononucleosis (IM) secondary to EBV can often be misdiagnosed as Streptococcus pharyngitis, as it was in this patient. Splenomegaly can develop and lead to splenic rupture, which is the most common cause of mortality in IM [1-4]. Atraumatic splenic rupture often presents as left upper quadrant pain upon palpation and left shoulder pain [5-6]. This is the only documented case of EBV-associated atraumatic splenic rupture presenting as cardiac arrest from hemorrhagic shock, resulting in patient survival without devastating sequelae.