(Kiosk 2) Cleared for Sports? Persistent Splenomegaly After Mononucleosis, or Is It?

Case Diagnosis: Splenomegaly from Infectious Mononucleosis

Case Description or Program Description: 17-year-old female with history of infectious mononucleosis presents for evaluation of persistent splenomegaly. Two months prior to presentation, she was given the official diagnosis of mononucleosis. She denied symptoms of chronic mononucleosis, early pharyngitis, chronic pain, fevers, or fatigue, and endorsed transient right lower back spasms. A series of ultrasounds were obtained by her PCP and demonstrated improvement in splenic enlargement: 12.8cm craniocaudal x 4.6cm transverse x 12.0cm AP --> 11.8cm x 5.3cm x 11.6cm --> 12.2cm x 4.4cm x 11.4cm. Her exam was largely unremarkable, including no oral lesions, rashes, or hepatosplenomegaly.

Setting: Outpatient Sports Medicine Clinic

Assessment/Results: Patient was cleared to return to ice-skating given normal liver function and CBC on follow-up studies, unlikelihood of rupture given time of diagnosis, improving spleen size, and current asymptomatic status. Interval CT abdomen pelvis imaging performed to rule out other causes of splenomegaly revealed stable splenomegaly at 12cm AP by 5 cm transverse by 10cm craniocaudal at 8 weeks post diagnosis. Splenic index and volume were 600 and 378cm3 respectively. No liver or spleen parenchymal abnormalities or lymphadenopathy.

Discussion (relevance): This is a unique case where return to play decisions for an athlete with persistent splenomegaly is challenged by a lack of evidenced-based guidelines and no standard for clearance after 8 weeks of persistent disease. There is less consensus on the appropriate spleen size in children. Our patient fell in the upper age limit of size for tall females which is about 12.6 cm in length, which could be perceived as normal vs splenomegaly. She had no chronic mono symptoms, normal labs, no other cause for chronic splenomegaly-- normal exam and we cleared her with risk vs benefit education/discussion.

Conclusions: Clinicians should use individualized decision-making and weigh risks versus benefits when clearing an athlete with borderline splenomegaly for sports.