Medical Image of the Week: Thoracic Splenosis

Figure 1. A: Axial CT of the chest without intravenous contrast demonstrates a cluster of soft tissue nodules adjacent to the left posterior hemi-diaphragm (blue arrows). B: Axial CT of the chest without intravenous contrast demonstrates absence of the spleen and a surgical clip (blue arrow) consistent with a prior splenectomy.

Figure 2. Fused technetium 99m-label sulfur colloid uptake study and axial CT of the chest without intravenous contrast demonstrates uptake of radiotracer in the previously seen soft tissue nodules adjacent to the posterior aspect of the left hemi-diaphragm (red arrows) which confirms the diagnosis of thoracic splenosis.

A 38-year-old man with a history of a motor vehicle collision about 20 years prior to presentation which resulted in multiple left-sided rib fractures, a left-sided pneumothorax requiring chest tube placement, and a high-grade splenic laceration necessitating an emergent splenectomy that presents to outpatient pulmonary clinic for evaluation of pulmonary nodules at the request of his primary care physician. He is asymptomatic. He has a 20-pack-year of smoking history and currently smokes 6 cigarettes per day. He denies any significant exposures or recent infections. He has a family history significant for heart disease and depression, but no history of malignancy. His vital signs and physical examination are normal. He had a CT of the chest performed with representative images from the study shown in Figure 1.

A nuclear medicine scan was subsequently requested which demonstrated uptake of the technetium 99m-labeled sulfur colloid in the soft tissue nodules adjacent to left hemi-diaphragm (Figure 2) confirming the diagnosis of thoracic splenosis. No further treatment or diagnostic work up was required.

Splenosis is defined as auto-transplantation of splenic tissue following traumatic or surgical disruption of the spleen. Splenosis usually occurs in the abdomen, most commonly in the left upper quadrant (1,2). However, with disruption of the diaphragm in the setting of trauma, splenic tissue can migrate into the thoracic cavity, and most often settles in the inferior, posterior left pleural space (as in our patient).  The diagnosis of thoracic splenosis should be suspected when one sees left basilar pleural nodules/masses in the setting of a previous trauma necessitating a splenectomy. A technetium 99m-labeled sulfur colloid study will demonstrate uptake of the radiotracer in the auto-transplanted splenic tissue as this radiotracer has a strong affinity for tissue arising from the reticuloendothelial system.

Gregory Gardner MD¹, Kevin Breen¹, Tammer Elaini MD², and Tiffany Ynosencio MD²

¹Department of Internal Medicine

²Division of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Khosravi MR, Margulies DR, Alsabeh R, Nissen N, Phillips EH, Morgenstern L. Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury. Am Surg. 2004 Nov;70(11):967-70. [PubMed]
2. Rosado-de-Christenson ML, Abbott GF. Diagnostic Imaging: Chest. 2^nd edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 30-1.

Cite as: Gardner G, Breen K, Elaini T, Ynosencio T. Medical image of the week: thoracic splenosis. Southwest J Pulm Crit Care. 2018;16(5):285-6. doi: https://doi.org/10.13175/swjpcc066-18 PDF

Medical Image of the Week: Recurrent Sarcoidosis Resembling Malignancy

Figure 1. CT scan showing multiple splenic masses.

The patient is a 64-year-old, non-smoking, woman who presented with a dry cough for a year and had a history of sarcoidosis. Five years ago, she presented with cough, bilateral pulmonary nodules and mediastinal adenopathy. At that time by a fine needle aspiration (FNA) under endobronchial ultrasound biopsy (EBUS), revealing non caseating granulomatous inflammation. She had complete remission after she was treated with a course of steroids. Follow up chest CT showed remission of her disease. On this presentation, she was found to have incidental multiple splenic masses on a CT scan of the chest (Figure 1). Physical examination was normal, CBC and chemistry were normal, and she had negative tests for tuberculosis, rheumatologic disease, systemic sclerosis, and mixed connective tissue disease. 

Pulmonary function tests were consistent with restrictive impairment and mild decrease in diffusion capacity for carbon monoxide. Positron Emission Tomography (PET scan) showed increased uptake corresponding to these lesions with no other areas of abnormal uptake in the body. CT-guided biopsy of splenic lesion showed non-caseating granulomas consistent with sarcoidosis. She was retreated with a course of steroids and a follow up CT scan of the abdomen showed resolution of the splenic masses.

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by non-caseating granulomas. It is thought to result from an exaggerated host cellular immune response to an unknown antigen. Although the lungs are involved in 90 % of patients, other organs can be affected with the lungs or in isolation. Visceral involvement is usually asymptomatic and presents as hepatosplenomegaly on physical exam, or less often as isolated nodular splenic lesions suspicious of lymphoma. Rarely patients can have elevated liver enzymes from liver involvement or cytopenias from splenic enlargement (1).

Other differential diagnoses include infectious, neoplastic or benign conditions that may have similar morphology, such as tuberculosis, histoplasmosis, and lymphomas, hemangiomas and hamartomas. Diagnosis is usually confirmed by a biopsy and the disease responds to steroid treatment in over 70% of patients (2). Splenectomy is a therapeutic option in cases of steroids failure, severe hypersplenism, inability to exclude malignancy, or if risk of splenic rupture is high (3).

Isolated splenic sarcoidosis is a rare condition that can be the first presentation of sarcoidosis or a site of disease recurrence. It can mimic a variety of infectious, benign or malignant conditions especially when it presents with cytopenias due to hypersplenism, making biopsy necessary. Fortunately, splenic sarcoidosis responds to steroid treatment in most patients. Splenectomy can be considered in refractory cases.

Fuad Zeid MD¹, Hasan S. Yamin MD¹, Ahmed Amro MD², Fadi Alkhankan MD³, and Hani Alkhankan MD⁴

¹Pulmonary and Critical Care and ²Internal Medicine

Marshall University

Huntington, WV USA

³Pulmonary and Critical Care

Mercy hospital/ St. Louis University

St. Louis, MO USA

⁴McLaren Oakland Pulmonary/Critical Care,

Pontiac, MI USA

References

1. Vakil A, MD, Upadhyay H, Sherani K, Cervellione K, Fein A. A case of splenic sarcoidosis: initial diagnosis and one-year symptom follow-up. Chest. 2014;145(3):210A [Abstract].
2. Calik M, Aygun M, Yesildag M, et al. Nodular splenic sarcoidosis: a rare case report and review of the literature. Chest. 2014;146(4):399A [Abstract].
3. Sharma OP, Vucinic V, James DG. Splenectomy in sarcoidosis: indications, complications, and long-term follow-up. Sarcoidosis Vasc Diffuse Lung Dis. 2002 Mar;19(1):66-70. [PubMed]

Cite as: Zeid F, Yamin HS, Amro A, Alkhankan F, Alkhankan H. Medical image of the week: recurrent sarcoidosis resembling malignancy. Southwest J Pulm Crit Care. 2018;18(5):279-80. doi: https://doi.org/10.13175/swjpcc057-18 PDF