Spleen peliosis also called peliosis of the spleen, splenic peliosis or peliosis lienalis is an extremely rare benign blood vessel condition characterized by multiple, randomly distributed, blood-filled and cyst-like cavities throughout the spleen 1), 2). The size of the lesions may vary from 1 millimetrer to several centimeters 3). Peliosis is a term derived from the Greek pelios, which means “dusky” or “purple,” referring to the color of the liver tissue with peliosis 4), 5). Spleen peliosis has also been reported, either alone 6), 7), 8), 9) or with peliosis hepatis (hepatic peliosis or liver peliosis) 10), 11), 12), 13), 14), 15), 16). Spleen peliosis often presents with spontaneous rupture of the spleen and requires urgent surgical intervention 17)), 18), 19), 20), 21), 22), 23), 24), 25), 26), 27), 28), 29), 30), 31). Numerous associations with medications and other conditions have been described in the literature, emphasizing the limited understanding of spleen peliosis 32). However, spleen peliosis may also be recognized as an incidental finding on computed tomography (CT) scans or at autopsy 33), 34), 35), 36), 37), 38), 39), 40).
Spleen peliosis may be idiopathic or associated with infections such as tuberculosis and Bartonella, hematological diseases such as myeloma, myelofibrosis, and Hodgkin’s disease and with the use of androgenic steroids and erythropoetin. Patients with isolated splenic peliosis may be asymptomatic or describe abdominal discomfort. It is often detected as an incidental finding on abdominal imaging or when spontaneous rupture occurs.
Spleen peliosis discovered on imaging should immediately prompt further evaluation. A differential diagnosis will often include malignant, infiltrative, or infectious conditions, as well as post-traumatic splenic cysts. The cysts of spleen peliosis are blood-filled and innumerable in quantity, distinguishing them from post-traumatic fluid-filled cysts of the spleen. Isolated peliosis of the spleen is extremely rare, and is therefore infrequently considered 41), 42), 43), 44). Imaging modalities for further assessing the spleen vary given the reason for testing and the differential diagnosis; they often include ultrasound, CT, positron emission tomography with CT (PET-CT), and magnetic resonance imaging 45), 46), 47). Despite these various imaging modalities, imaging may be inadequate for establishing a clear diagnosis 48), 49). While spleen peliosis often exists without symptoms, atraumatic spleen rupture, requiring urgent surgical intervention is a well-established presentation of spleen peliosis 50)), 51), 52), 53), 54), 55), 56), 57), 58), 59), 60), 61).
As there are no clear published guidelines on the management of spleen peliosis, the definitive management of splenic rupture due to peliosis is emergency splenectomy 62), 63), 64), 65). However, prophylactic splenectomy is still debatable if accidental radiological findings were established upon regular check-ups or unrelated complaints 66).
Figure 1. Spleen peliosis
Footnotes: Contrast-enhanced CT scan from a 44-year-old otherwise healthy man presented with left-upper quadrant and left-shoulder pain. The patient denied trauma. A CT scan revealed splenomegaly with multiple splenic cysts and free intraperitoneal fluid consistent with blood. (A) Coronal view, (B) Axial view at the level of L1, (C) Axial view at the level of T12. Significant splenomegaly (14 × 11 × 9 cm). Multiple, loculated, cystic lesions are noted throughout the spleen. The largest cystic lesion measures 9.3 cm in diameter. A minor hemoperitoneum (not visible) was present on the scan.[Source 67) ]
Figure 2. Spleen peliosis ultrasound
Footnote: A 3-year-old girl with splenic peliosis. Longitudinal ultrasonography of the spleen shows splenomegaly and multiple poorly defined hypoechoic nodules (arrow).[Source 68) ]
Figure 3. Spleen peliosis rupture
Footnotes: (A) Spleen ultrasound appearance at diagnosis. (B) Ultrasound spleen appearance in peliosis rupture. Ultrasonographic imaging showed inhomogeneous splenic parenchyma and increased size. (C) Abdominal computer tomography (CT) frame. CT showed hemoperitoneum and marked splenomegaly (with a pole-to-pole diameter of about 200 mm) with many hyperdense areas.[Source 69) ]
Spleen peliosis cause
The cause of spleen peliosis remains unclear 70). Several causative factors were suggested to be associated with peliosis in the spleen, including the following: intravenous drug abuse, the usage of anabolic steroids, danazol, chronic alcohol use, granulocyte colony-stimulating factor (GSCF) use, tamoxifen, azathioprine, androgens, chemotherapy, liver cirrhosis, tuberculosis, oral contraceptive pills, human immunodeficiency virus (HIV), Hodgkin’s disease, aplastic anemia, and myeloma 71), 72), 73), 74), 75), 76), 77), 78), 79), 80), 81), 82), 83), 84), 85), 86), 87), 88), 89), 90), 91), 92), 93), 94). A number of reported patients were also noted to have blood disorders including multiple myeloma, aplastic anemia, Hodgkin disease, and myelofibrosis 95), 96), 97), 98), 99), 100), 101), 102), 103), 104).
Preliminary evidence links the development of peliosis to angiogenesis (formation of new blood vessels) due to elevated levels of vascular endothelial growth factor (VEGF) 105). VEGF is a fundamental regulator of physiologic angiogenesis. Elevated VEGF levels are known to be associated with tumor progression and poor outcomes in a number of cancers. A condition resembling peliosis has been demonstrated in mice with elevated VEGF levels, that were found to have massively dilated hepatic sinusoids and endothelial cell proliferation and apoptosis 106). The experimental link to elevated VEGF levels, warrants investigation into the treatment of peliosis with anti-angiogenic factors 107).
Spleen peliosis risk factors include:
- use of anabolic steroids
- hematological conditions such as aplastic anemia
- wasting diseases such as
- concurrent malignancy
Spleen peliosis symptoms
Patients with spleen peliosis are commonly asymptomatic, and splenic peliosis may present as an incidental finding during imaging studies for other diseases, at autopsy, or with spontaneous rupture of the spleen after minimal or no trauma 108). Although uncommon, some reports suggest that males, ages > 20 years, presence of splenomegaly, and use of chemotherapy might be associated with increased risk of spontaneous splenic rupture in hematology 109). One literature review has shown that all the reported spleen peliosis cases collected from 1980 till 2016 had either presented with abdominal pain or circulatory shock 110). Most cases of spleen peliosis are associated with peliosis hepatis (peliosis of the liver) 111).
Spleen peliosis diagnosis
Spleen peliosis hepatis is very difficult to diagnose because it is usually asymptomatic, and extreme rarity. Peliosis diagnosis is usually obtained after histopathological examination of the resected organ or at autopsy. Radiological imaging shows a broad spectrum of appearances because of its dependence on the blood supply to the lesions. Ultrasound shows multiple poorly defined hypoechoic lesions (Figure 2) and hyperechoic thrombosis 112). The finding of cyst-like hypodense lesions which do not cause mass effect on vessels on contrast-enhanced CT should alert the radiologist to the diagnosis of spleen peliosis. This is of importance in recognizing the risk of spontaneous splenic rupture and in avoiding interventional procedures, such as liver biopsy or percutaneous transhepatic cholangiography, which may precipitate life-threatening iatrogenic organ rupture.
Peliosis histological appearance is characterized by multiple blood-filled cystic cavities primarily involving the mononuclear phagocytic system (liver, spleen, bone marrow, and lymph nodes).
Once the presence of peliosis has been established it is proposed that all necessary investigations be pursued to detect its presence in other organs and to establish a possible cause 113). The implications for this are clear. Spontaneous rupture of the spleen remains an ever-present threat. Physicians should be mindful of this in the event that anticoagulation or thrombolysis is being considered. In addition, the presence of peliosis may prompt the investigation and subsequent discovery of equally serious underlying conditions, for example immunodeficiency or malignancy.
Spleen peliosis treatment
Hemorrhage associated with splenic peliosis is quite amenable to surgical therapy if recognised and treated promptly 114). The existing literature does not however explore the surgical management of patients in whom an incidental diagnosis of splenic peliosis has been made. The introduction of laparoscopic splenectomy has reduced significant morbidity when compared with open surgery 115). Prophylactic laparoscopic splenectomy has been advocated to prevent organ rupture in conditions such as splenic sarcoidosis 116). The role of elective splenectomy in splenic peliosis is not known.
From the patient’s perspective, lifestyle changes may be necessary. Younger patients should be encouraged to avoid high-risk activities, for example, contact sports 117). It would seem wise to avoid or discontinue the oral contraceptive pill, and seek alternative forms of contraception. In addition any attending physician should be aware when other medications thought to cause peliosis are being considered 118).
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