|
 
 |
| CASE REPORT |
|
| Year : 2017 | Volume
: 4
| Issue : 4 | Page : 144-146 |
|
Pelvic splenosis presented as pelvis mass and gross hematuria
James Jing1, Run Wang2
1 Department of Radiology, Baylor College of Medicine; Department of Radiology, Baylor St. Luke's Medical Center, 6720 Bertner Avenue MC2-270, Houston, Texas 77030, USA
2 Division of Urology, McGovern Medical School, University of Texas; Department of Urology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| Date of Web Publication | 29-Dec-2017 |
Correspondence Address:
Dr. James Jing
Department of Radiology, Baylor St. Luke's Medical Center, 6720 Bertner AV MC 2-270, Houston, TX. 77030
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jina.jina_20_17
Pevlic splenosis is a very rare condition, particularly when the condition is diagnosed during a hematuria workup. Hematuria can be caused by genitourinary system infection, urolithiasis, neoplasm, or trauma. Hematuria can be seen in patients with symptoms or without symptoms. The standard work-up for hematuria includes a computed tomography (CT) scan which can sometimes have incident findings that can make diagnosis difficult. We report a rare case of a 44-year-old patient with painless gross hematuria and the CT scan revealed a pelvic mass that was eventually confirmed to be a pelvic splenosis by a nuclear liver–spleen sulfur colloid scan.
Keywords: Hematuria, pelvic mass, splenectomy
How to cite this article:
Jing J, Wang R. Pelvic splenosis presented as pelvis mass and gross hematuria. J Integr Nephrol Androl 2017;4:144-6 |
| Introduction | |  |
Ectopic splenic tissue can be found in the body in two forms: accessory spleens and splenosis. Accessory spleens are congenital and arise from the left side of the dorsal mesogastrium during the embryological period of development.[1] Splenosis is an acquired condition of autotransplantation of viable splenic tissue during surgery or trauma. Splenosis presented as pelvic mass during a hematuria workup is extremely rare.
| Case Report | | |
A 44-year-old male patient presented with painless gross hematuria after vigorous activity. All laboratory results were negative. The physical findings were unremarkable. The patient had a fall accident at the age of 18 and underwent splenectomy. The patient stated similar prior episode of painless gross hematuria 10 years ago. The patient stated spontaneous resolution of hematuria without medical intervention.
Computed tomography (CT) was performed with use of intravenous contrast.
CT of the abdomen and pelvis demonstrated the surgical absence of spleen [Figure 1]. A 5 cm × 4 cm enhancing mass in the pelvis originated from the left seminal vesicle and extended to the anterior wall of the rectum [Figure 2]. No adenopathy was seen in the abdomen or pelvis. The spleen was not seen. Incidental note was made of liver hemangioma. A nuclear liver spleen sulfur colloid scan was performed. The study demonstrated normal update in the liver and absence of uptake in the left upper quadrant abdomen [Figure 3]. Abnormal uptake in the pelvis was noted in the single-photon emission computed tomography sulfur colloid scan compatible with pelvic splenosis [Figure 4]. | Figure 1: Computed tomography of the upper abdomen demonstrates surgically absence of spleen. Soft tissue density in the left upper quadrant abdomen is the tail of the pancreas (white arrow). Incidental note is made of hemangioma in the liver (black arrow)
Click here to view |
 | Figure 2: Computed tomography of the pelvis demonstrates a mass (white arrow) in the region of the left seminal vesicle (white arrow head) and anterior wall of the rectum
Click here to view |
 | Figure 3: Tc99m sulfur colloid liver spleen scan demonstrates absence of the splenic uptake
Click here to view |
 | Figure 4: Single-photon emission computed tomography image of the sulfur colloid study demonstrates abnormal uptake in the pelvis corresponding the pelvis mass seen on the computed tomography examination
Click here to view |
The patient's hematuria resolved spontaneously without any intervention. He was followed up for more than two years without any further episode of hematuria.
| Discussion | | |
There are many causes of hematuria.[2] Some patients who have hematuria are complained of flank pain. A small percentage of patient is asymptomatic. Hematuria can be caused by genitourinary system infection, urolithiasis, neoplasm, or trauma. The most common cause of hematuria is urolithiasis. For patients with hematuria and flank pain, CT of the abdomen and pelvis is the first radiological study of choice. CT examination can easily detect urolithiasis with or without obstruction, pyelonephritis, cystitis, renal, or bladder neoplasm.
A negative CT examination may require further investigation with cystoscopy or retrograde pyelogram to exclude subtle transitional neoplasm of the genitourinary system. However, it is common that CT scan will have incident findings that can sometimes make the diagnosis difficult. In our case, it was initially believed that the hematuria was related to the pelvic mass that was highly suspicious for neoplasm and even a biopsy was initially suggested.
Any further investigation should correlate with patient's medical history and radiological study. Patient with any history of splenic rupture and abdominal or pelvis mass in the region of the genitourinary tract should undergo a nuclear liver spleen sulfur colloid scan to exclude splenosis before any invasive testing, such as biopsy.
Splenosis is one type of ectopic splenic tissue. It is an acquired condition and is defined as the autoimplantation of one or more focal deposits of splenic tissue in various compartments of the body.[3],[4],[5],[6]
Abdominal or pelvis splenosis is seen after abdominal trauma or surgery. They result from the seeding of the peritoneal cavity. The splenic tissue recruits a local blood supply. The splenosis could be solitary or multiple. The splenosis could be small and asymptomatic as incidental findings. They may grow quite large and asymptomatic at the time of diagnosis.
In this patient, initial CT of the abdomen and pelvis revealed an enhancing mass in the pelvis in the region of the left seminal vesicle. An enhancing mass of any nature would be alarming. Since the mass was in the region of the seminal vesicle, neoplasm should be considered. Considering patient's medical history of splenic rupture and splenectomy, this mass could be ectopic pelvic splenosis. This was proven on the subsequent nuclear liver spleen sulfur colloid scan, and hence, the biopsy was avoided. The CT examination did not demonstrate genitourinary tract infection, urolithiasis, or renal mass. This patient's gross hematuria was probably related to his vigorous activity and may not have been caused by the splenosis. Considering patient's history of splenectomy and prior episode of hematuria, the current hematuria is a very less likely infection, urolithiasis, or neoplastic related. The nuclear scan demonstrated pelvic mass to be pelvic splenosis. No other radiological or urological investigation is needed.
The splenosis could be in the thorax, intrahepatic, intrapancreatic, abdominal, or pelvic cavity. They can cause serious diagnostic problems. The splenosis are benign and do not require surgical intervention. It is essential to distinguish splenosis from malignant neoplasm. Nuclear liver spleen sulfur colloid scan should be utilized in the right clinical settings.
| Conclusion | | |
The nuclear liver spleen sulfur colloid scan is the right diagnostic for splenosis. It is essential to perform nuclear liver spleen sulfur colloid scans in patients presented with abdominal or pelvis mass/masses who have histories of splenic injury or have undergone splenectomy. This noninvasive imaging study can avoid the risks of biopsy that may cause severe potential bleeding of the ectopic spleen.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and clinical information to be reported in the journal. The patient understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Fremont RD, Rice TW. Splenosis: A review. South Med J 2007;100:589-93.  |
| 2. | Hicks D, Li CY. Management of macroscopic haematuria in the emergency department. Emerg Med J 2007;24:385-90. |
| 3. | Liu Y, Ji B, Wang G, Wang Y. Abdominal multiple splenosis mimicking liver and colon tumors: A case report and review of the literature. Int J Med Sci 2012;9:174-7. |
| 4. | Ksiądzyna D. A case report of abdominal splenosis – A practical mini-review for a gastroenterologist. J Gastrointestin Liver Dis 2011;20:321-4. |
| 5. | Ferraz R, Miranda J, Vieira MM, Carlos Mota J. Thoracic splenosis. Rev Port Cir Cardiotorac Vasc 2010;17:153-5. |
| 6. | Short NJ, Hayes TG, Bhargava P. Intra-abdominal splenosis mimicking metastatic cancer. Am J Med Sci 2011;341:246-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
|
Search Pubmed for