Splenic hemangiomatosis.

CASE REPORT A 56-year-old woman saw her primary care provider for progressive left fl ank pain with bulging of the left side of the abdomen. A magnetic resonance imaging (MRI) study of the thoracic spine without contrast enhancement incidentally discovered the spleen to be enlarged and largely replaced with cystic lesions (Figure 1). Further discussions with the patient revealed that she had presented to an outside hospital 3 years earlier and had been diagnosed with biliary pancreatitis. A computed tomography (CT) study of the abdomen had been performed and was reported to show splenomegaly with multiple splenic cysts of various sizes. An emergent laparoscopic cholecystectomy was performed during the patient’s admission to the outside hospital. Th e operation was complicated by postoperative bleeding, requiring exploration. No active bleeding was encountered; however, a large amount of hemoperitoneum was seen. Rupture of a splenic cyst was proposed as the source of the hemoperitoneum. Th e patient recovered well and in the interim between presentations also underwent an open Roux-en-Y gastric bypass for morbid obesity. On examination at Baylor University Medical Center at Dallas, a reducible midline incisional hernia was found and the spleen was palpated four fi ngerbreadths below the left costal margin. A CT study of her abdomen with intravenous contrast enhancement showed splenomegaly with near complete replacement of the normal splenic parenchyma by cysts of various sizes, some of which had peripheral curvilinear calcifi cation or central coarse calcifi cation (Figure 2). An incidental 1-cm exophytic solid mass was also discovered arising from the interpolar left kidney, concerning for renal cell carcinoma (Figure 3). An open surgery was planned for wedge resection of the kidney lesion, splenectomy, and incisional hernia repair. Two weeks prior to the planned operation, the patient received pneumococcal, meningococcal, and haemophilus infl uenza type B vaccinations. Intraoperatively, an extensive adhesiolysis was performed. Th is was followed by splenectomy, wedge resection of the left kidney lesion, and ventral hernia repair with mesh. Th ere was no evidence of echinococcal disease or splenosis in the abdomen. Th e spleen was enlarged and appeared to be almost completely replaced by a cystic process (Figure 4).