Acute Febrile Illness and a Splenic Mass in a 15‐Year‐Old West African Immigrant

Abstract

Within 24 h of arrival from West Africa, a 15-year-old boy presented to the emergency department with periumbilical abdominal pain, intermittent bloody diarrhea, vomiting and fever of three days duration. He had lived in refugee camps for over 10 years. His physical examination was remarkable for fever (40.7°C), thin body habitus (height and weight below the fifth percentile for age), scleral icterus and hepatosplenomegaly (liver palpable 2 cm below the right costal margin, span 11 cm; spleen tip 5 cm below the left costal margin). The abdomen was somewhat tender to palpation but soft, and his bowel sounds were normal. Investigations showed rare malaria parasites in the peripheral blood smear; numbers were insufficient for speciation. Stool was negative for Salmonella, Shigella, Escherichia coli 0157, Campylobacter, Aeromonas and Yersinia. Serology results for Leptospira, hepatitis A and HIV were negative. Results for hepatitis B surface antigen were positive. Cultures of blood and urine showed no growth. Serology for Epstein-Barr virus (EBV) showed the presence of immunoglobulin G to viral capsid antigen, but no immunoglobulin M was identified. A single-step Mantoux test was negative. Imaging of the liver and spleen showed a normal-looking liver, but revealed the presence of three splenic masses. Computed tomography identified two cystic lesions diagnosed as peripheral splenic infarcts, and one large noncystic mass that seemed to originate in the spleen and extend outward (Figure 1). Figure 1 Computed tomography of the abdomen of a 15-year-old male immigrant from West Africa with hepatosplenomegaly and multiple splenic lesions A spleen biopsy was performed. What is the diagnosis?