*From the Departments of Radiology (Drs. Gopal and Greaves) and Cardiothoracic Surgery (Mr. Jones), South Manchester University Hospitals, Manchester, UK.
Correspondence to: Karthikeyan Gopal, MRCP, Specialist Registrar, South Manchester University Hospitals, Wythenshawe, Manchester. M23 9LT UK; e-mail:email@example.com
A 33-year-old Turkish Cypriot man living in the United Kingdom was seen in the emergency department for chest pain. He was aware of the pain for some weeks, and on the day of hospital admission it worsened significantly and radiated to the left arm and back. It was constant, not pleuritic, and settled spontaneously over a period of 3 h. He smoked heavily and worked as a catering manager. His weight was stable with no other symptoms. His medical history was significant for abdominal injury sustained at the age of 5 years in a hand grenade incident that resulted in the death of his brother. He underwent laparotomy with a splenectomy at that time. Clinical examination revealed several abdominal wall scars but was otherwise unremarkable.
The chest radiograph obtained in the emergency department demonstrated a large, left-sided, pleural-based mass adjacent to the costal margin with several small ipsilateral pleural nodules adjacent to the heart (Fig 1
). Contrast enhanced CT confirmed the presence of multiple enhancing pleural nodules and masses confined to the left hemithorax. The largest of these measured 2 cm by 9 cm and corresponded to the large pleural mass seen on the chest radiograph (Fig 2
). In addition, there were several small enhancing nodules in the left upper quadrant of the abdomen and several small metallic fragments in the abdominal wall (Fig 3
). The spleen was absent. This pleural-based mass remained unchanged on an 8-week follow-up chest radiograph. A 99mTc sulfur colloid scan was obtained to confirm the diagnosis. Abnormal uptake was demonstrated within the pleural and abdominal nodules (Fig 4
Splenosis is the auto-transplantation of splenic tissue after splenectomy for traumatic or iatrogenic injury to the spleen.1Splenic implants derive their blood supply from surrounding tissue and grow into mature splenic tissue. The splenic fragments may implant on parietal or visceral pleura, the pericardium, and within the peritoneal cavity.2–3 Rarely, they may also implant in a lung if there is an associated parenchymal laceration, and have been described within subcutaneous tissue at the site of incision. Thoracic splenosis occurs exclusively within the left hemithorax.
Thoracic splenosis to our knowledge has not been associated with symptoms. In the abdomen, it can cause GI hemorrhage when tissue implantation occurs in the stomach or small bowel.4It can also cause abdominal pain due to intraperitoneal nodule infarction, bowel obstruction, or hematoma from trauma to the preexisting splenic implant.5Flank pain from ureteral compression and hydronephrosis has also been reported.6We postulate that partial infarction of the large pleural mass may have caused our patient’s symptoms. Splenotic nodules typically grow after implantation7and the implanted splenic tissue offers some degree of protection against bacterial infection lowering the frequency of postsplenectomy sepsis.8
Splenosis is normally discovered incidentally as a pleural nodule or mass on a chest radiograph or unrelated diagnostic imaging. The average reported interval between trauma and diagnosis is 18.8 years, and unfortunately most splenotic nodules are mistaken for pleural or parenchymal neoplastic lesions; thoracotomy is often performed to make the diagnosis. The CT shows nonspecific round or oval soft-tissue pleural or parenchymal masses. Magnetic resonance, along with the administration of superparamagnetic iron oxide, may be helpful and results in loss of signal intensity in all pulse sequences similar to that seen within normal spleen.9While sulfur colloid scintigraphy is the initial procedure of choice for splenic imaging,10selective splenic scintigraphy with damaged RBCs is especially important when colloid scanning is equivocal for any reason.11
The findings of a pleural-based nodule in a subject with a history of thoracoabdominal trauma should raise the possibility of thoracic splenosis. This diagnosis can be confirmed noninvasively with sulfur colloid scanning, obviating the need for thoracotomy.
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