In this episode we are joined by Haematology Specialist Registrar Dr Claire Kelly to discuss splenomegaly and some important haematological disorders as potential stations in the MRCPI Part II clinical exam.
We discuss the approach, physical findings, a differential diagnosis, investigations and management. We then go on to briefly talk through some potential follow-up questions including differentiating a large spleen versus a large kidney, management of Chronic Myeloid Leukaemia (CML) and Myelofibrosis, a brief review of Autoimmune Haemolytic Anaemia (AIHA) and Immune Thrombocytopenia (ITP), splenectomy indications and splenectomy precautions.
Common causes of splenomegaly in exams are CML and myelofibrosis.
A possible way to learn and work through a splenomegaly differential diagnosis (taken from Pastest Splenomegaly case notes):
The causes of splenomegaly can be stratified into three main categories:
"1 . Infiltration, malignant or benign - (including myeloproliferative and
lymphoproliferative disorders), lymphomas, amyloidosis, sarcoidosis, Gaucher’s
disease (ie lipid storage disease), thyrotoxicosis.
2. Increased function – with increased removal of defective red blood cells with
spherocytes, thalassaemia, nutritional anaemias and early sickle cell anaemia.
Also there is immune hyperplasia in response to infection (viral, bacterial, fungal or
parasitic) including tropical splenomegaly with chronic malaria and visceral
leishmaniosis i.e. Kala-azar. Also consider glandular fever, infectious hepatitis,
subacute bacterial endocarditis, brucellosis and disordered immunoregulation
(rheumatoid arthritis with Felty’s syndrome, SLE, sarcoidosis)
3. Abnormal blood flow, either with cirrhosis, or secondary to a vascular
problem, such as hepatic or portal vein obstruction.
As there are so many causes of splenomegaly, you may find the examiner will give you a clue
to guide you to the diagnosis. Listen carefully for this.
So, for example, if the examiner asks you to examine this farmer’s abdomen, they may be likely
to have Brucellosis. If you were only asked to examine the abdomen itself but given an
opportunity to examine elsewhere, you may request to examine the throat for glandular fever.
If the examiner asks you to examine this man and informs you he is an Ashkenazi Jew, there may
be increased likelihood that the patient may have type 1 Gaucher’s.
If you are informed the patient has recently returned from Africa, then you should consider
chronic malaria, although there would likely be other clinical features such as anaemia."
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Episode external review by Dr Louisa Shackleton, Haematology SpR
Consultant supervisor Professor Declan Byrne, consultant physician St James's Hospital, Dublin
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