Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: systematic literature review

Background: In Epstein-Barr virus mononucleosis, the spleen is always implicated and predisposes to splenic rupture, often without a trauma, and infarction. Preserving the spleen is nowadays the goal of the management to avoid post-splenectomy infections. Methods: To characterize these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible were articles describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis. Results: In the literature we found 171 articles, published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (N=139) of cases occurred within three weeks after onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery score of splenic rupture, which was retrospectively calculated, and the surgical management: splenectomy in 84% (N=44) of cases with severe, and in 58% (N=70) of cases with moderate or minor score (P=0.001). Mortality rate of splenic rupture was 4.8% (N=9). In splenic infarction, an underlying hematologic condition was observed in 21% (N=6) of cases. The treatment of splenic infarction was always conservative without any fatal course. Conclusions: Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a preexisting hematologic condition