(Chest. 2002;122:718-720.)
© 2002
American College of Chest Physicians
Pleural Nodularity in a Patient With Pyrexia of Unknown Origin*
Peter B. Wold, MD and
Michael A. Farrell, MD
* From the Department of Radiology, Mayo Clinic, Rochester, MN.
Correspondence to: Michael A. Farrell, MD, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55902; e-mail: farrell.michael{at}mayo.edu
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Introduction
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A 26-year-old man with a history of intermittent fever of unknown etiology for the past 1.5 years presented to our institution with a 2-day history of fever, night sweats, and myalgias. His medical history was unremarkable except for a laparotomy at the age of 6 years following an accidental gunshot wound to the abdomen. He admitted having a previous blood transfusion and recreational use of cocaine and marijuana. Physical examination revealed a depressed affect and multiple skin tattoos, but findings were otherwise negative. CBC count demonstrated a mild leucocytosis (13.6 x109/L; normal range, 3.4 to 10 x 109/L) and associated lymphocytosis (6.2 x 109/L; normal range, 0.9 to 2.9 x 109/L). Results of extensive laboratory testing (infection, immunology, and biochemistry) were otherwise unrevealing. The appearance of an abnormality on the chest radiograph (Fig 1
) led to a CT study (Fig 2
) and a possible biopsy because of concerns about underlying malignancy. The CT findings prompted another diagnostic study (Fig 3
), and so the biopsy was canceled.
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Figure 2.. CT (lung window settings) demonstrates multiple pleural-based nodules in the left base. Mild pleural thickening appears bilaterally. CT of the upper abdomen (not shown) demonstrated that the spleen was absent.
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Figure 3.. Coronal single-photon emission CT images from a 99mTc sulfur colloid study demonstrate focal areas of increased isotope uptake at the base of the left lung (arrowheads) corresponding to the abnormality on the CT study. The spleen is absent. There is normal uptake in the liver and bone marrow.
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What is the diagnosis?
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Diagnosis: Thoracic splenosis
Splenosis is defined as the autotransplantation of splenic tissue after disruption of the splenic capsule, usually following splenic rupture. It occurs most commonly in the peritoneum, omentum, and the mesentery, where nodules of splenic tissue are seen. Return of antimicrobial function can occur in the autotransplanted splenic tissue, which likely explains the lower incidence of sepsis in children who undergo splenectomy for trauma, compared to any other indication.1
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Shaw and Shafi3
first reported thoracic splenosis as an autopsy finding. It is an uncommon phenomenon, with 29 previous cases reported in the English-language literature4
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(23 men and 6 women; age range, 15 to 74 years). All patients had a history of combined abdominal and thoracic trauma. The causative agent was a gunshot wound in 17 patients, shrapnel injury in 2 patients, motor vehicle accident in 7 patients, and unknown circumstances in 3 patients. Splenectomy was performed in all patients. The thoracic splenosis became evident from 1 to 42 years after the injury. The nodules were multiple in 15 patients, solitary in 13 patients, and of indeterminate number in 1 patient. All lesions were extrapulmonary and associated with the visceral or parietal pleura. A mediastinal implant in a patient with left lower lobectomy at the time of injury, and subcutaneous implants in a different patient with history of chest tube placement at the time of injury were reported.5
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All patients were asymptomatic, with the exception of one patient with hemoptysis and another patient with pleurisy.4
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The appearance of multiple, extrapulmonary, pleural-based nodules and masses on chest radiography and CT is nonspecific. Differential considerations include pleural metastases (lung, breast, GI tract, pancreas, kidneys, and ovaries), lymphoma, asbestos-related pleural plaques, mesothelioma, and invasive thymoma by contiguous extension. A history of thoracoabdominal trauma, splenectomy, and findings of left-sided, extrapulmonary, pleural-based nodule(s) should indicate the diagnosis of thoracic splenosis. A radiologic diagnosis can be confirmed by either a 99mTc sulfur colloid, 111I-labeled platelet, or 99mTc heat-damaged erythrocyte study, which all result in increased uptake of the radioactive isotope in the ectopic splenic tissue. Including our case, only 10 of the 30 cases reported in the English-language literature have been confirmed by nuclear scintigraphy,6
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with the remainder confirmed at biopsy, surgery, or autopsy. However, transthoracic fine-needle aspiration cytology of thoracic splenosis may create pitfalls in diagnostic interpretation when populations of small and medium-sized lymphocytes may erroneously suggest a lymphoproliferative disorder.12
Radiologic diagnosis avoids biopsy or operation and preserves the patient’s remaining splenic tissue. No specific cause for the patient’s symptoms was found, and the patient will continue to be followed up.
Received for publication February 14, 2001.
Accepted for publication April 24, 2001.
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References
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- Pearson, HA, Johnston, D, Smith, KA, et al (1978) The born-again spleen: return of function after splenectomy. N Engl J Med 298,1389-1392[Abstract]
- Singer, DB Postsplenectomy sepsis. Perspect Pediatr Pathol 1973;1,285-305[Medline]
- Shaw, AFB, Shafi, A Traumatic autoplastic transplantation of splenic tissue in man with observation of the late results of splenectomy in six cases. J Pathol 1937;45,215-235[CrossRef]
- Cordier, JF, Gamondes, JP, Marx, P, et al Thoracic splenosis presenting as hemoptysis. Chest 1992;102,626-627[Abstract/Free Full Text]
- Hardin, VM, Morgan, ME Thoracic splenosis. Clin Nucl Med 1994;19,438-440[CrossRef][ISI][Medline]
- Madjar, S, Weissberg, D Thoracic splenosis. Thorax 1994;49,1020-1022[Abstract/Free Full Text]
- Singh, P, Munn, NJ, Patel, NK Thoracic splenosis [letter]. N Engl J Med 1995;333,882[Free Full Text]
- O’Connor, JV, Brown, CC, Thomas, JK, et al Thoracic splenosis. Ann Thorac Surg 1998;66,552-553[Abstract/Free Full Text]
- Buchino, JJ, Buchino, JJ Thoracic splenosis. South Med J 1998;91,1054-1056[ISI][Medline]
- White, CS, Meyer, CA General case of the day: thoracic splenosis. Radiographics 1998;18,255-257[ISI][Medline]
- Fidvi, SA, Kroop, SA, Klein, SA Posttraumatic thoracic splenosis and chronic aortic pseudoaneurysm. J Thorac Imaging 1999;14,300-302[ISI][Medline]
- Renne, G, Coci, A, Biraghi, T, et al Fine needle aspiration of thoracic splenosis: a case report. Acta Cytol 1999;43,492-494[ISI][Medline]
- Naylor, MF, Karstaedt, N, Finck, SJ, et al Noninvasive methods of diagnosing thoracic splenosis. Ann Thorac Surg 1999;68,243-244[Abstract/Free Full Text]
- Velitchkov, NG, Kjossev, KT, Losanoff, JE, et al Subcutaneous splenosis: a clue to diagnosis of thoracic splenosis. J R Coll Surg Edinb 2000;45,66[ISI][Medline]
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Introduction
What is the diagnosis?
