Venting the Spleen

A CLINICAL PROBLEM-SOLVING article by Neal Varughese from Yale University School of Medicine, New Haven, CT.
A 19-year-old woman presented with a 4-day history of abdominal pain, located in the right upper quadrant and epigastrium, with occasional radiation to her back. She also noted profound fatigue and a 13.6-kg weight loss during the preceding months. The patient had a history of hereditary spherocytosis. Ten years earlier, she had undergone laparoscopic splenectomy and cholecystectomy for chronic hemolytic anemia with symptomatic gallstones, with complete resolution of the hemolytic crises.
At current presentation, ultrasonography and CT showed a well-defined, noncystic lesion, measuring 4.5 cm in diameter, originating from the inferomedial aspect of the right side of the liver. One month later, abdominal pain, fatigue, and sore throat persisted. Several tender, slightly firm, mobile lymph nodes measuring as large as 2 cm in diameter were palpated in the anterior and posterior cervical, left supraclavicular, and bilateral inguinal regions.
In this patient, a lymphoproliferative, infectious, or inflammatory disorder seems likely. In the case of a common disease in a patient with an uncommon coexisting condition, a close collaboration among clinicians, pathologists, surgeons, and radiologists was required.