UNIQUE CASE OF ISOLATED CONGESTIVE SPLENOMEGALY DUE TO ALCOHOLIC CARDIOMYOPATHY RESULTING IN PANCYTOPENIA

Abstract

SESSION TITLE: Cardiomyopathy Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Isolated splenomegaly has a prevalence of 2% in USA. Etiologies include congestive, infiltrative, immune, and neoplastic. Congestive splenomegaly occurs due to portal hypertension (PHTN) or thrombosis. Alcohol causes a dose-dependent dilated cardiomyopathy, hematopoietic, and granulopoietic stem cell suppression.CASE PRESENTATION: A 49 year-old male with a history of alcoholic cardiomyopathy (ACM) and HCV presented with shortness of breath and anasarca. Vitals demonstrated tachycardia. Physical exam was significant for pitting edema to the upper chest wall with a palpable, non-tender, mobile spleen tip. Platelets were 124 B/L with unremarkable LFTs and INR. Echocardiogram demonstrated an EF of 15%. A bumetanide infusion was required for diuresis. He developed pancytopenia with nadirs of HGB 10.6 g/dL, PLT 77 B/L and WBC 1.5 B/L. US doppler of the abdomen showed ascites and splenomegaly with hepatic vein dilation of 1.2 cm. CT abdomen with contrast redemonstrated US abdomen findings, without cirrhosis, vascular abnormalities or lymphadenopathy. A negative infectious workup included blood cultures, serologies for EBV, CMV, HIV, and parasite smear. Hematologic workup showed iron-deficiency anemia (IDA) with normal reticulocyte count, B12, folate, haptoglobin, and LDH. Blood smear was negative for morphology suggesting myelodysplastic syndrome, hematologic malignancy, or immune thrombocytopenia. Outpatient elastography was negative for cirrhosis. The patient was diagnosed with pancytopenia secondary to congestive splenomegaly from severe ACM and alcoholic myelosuppression.DISCUSSION: Splenomegaly is diagnosed by a palpable spleen or by imaging. Initial workup should include a CBC to evaluate for abnormal WBCs to rule out myeloproliferative disorders. Biopsy of bone marrow, lymph nodes, or a flow cytometry can reveal malignancy. Infectious workup should test for EBV, CMV, parasitemia, HIV, blood cultures, and other serologies if appropriate. US venous doppler and MRA assist in diagnosing vascular or primary splenic lesions. Splenectomy and pathologic evaluation remain gold-standard for diagnosis of isolated splenomegaly. Evaluation of pancytopenia includes blood smear, iron studies, ESR, CRP, LFTs, reticulocyte count, LDH, direct Coombs test, and evaluation for drug interactions. The spleen can swell eight to ten times its size, resulting in platelet sequestration and WBC phagocytosis. Alcohol causes dose-dependent myelosuppression, concurrently impairing leukocyte development, and chemotaxis.CONCLUSIONS: In the absence of positive infectious, immune, neoplastic and hepatic pathology, this patient’s splenomegaly is likely the result of his severe ACM. While congestive splenomegaly is typically associated with portal hypertension, this rarely occurs without concurrent cirrhosis. Splenomegaly typically affects platelets and WBC but alcoholic myelosuppression and concurrent IDA caused his anemia.Reference #1: Chapman J, Bansal P, Goyal A, Azevedo AM. Splenomegaly. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2021. PMID: 28613657.Reference #2: Ballard HS. The hematological complications of alcoholism. Alcohol health and research world. 1997;21(1):42-52. https://www.ncbi.nlm.nih.gov/pubmed/15706762.Reference #3: Manappallil RG. Acute onset pancytopenia following alcohol heavy drinking. Asian Journal of Bio-Medical Research. Apr-Jun. 2016;2(2).DISCLOSURES: No relevant relationships by Sameer AkhtarNo relevant relationships by Sean CoulsonNo relevant relationships by Brian ThomasNo relevant relationships by Rohan UmraniNo relevant relationships by Yvette Wang SESSION TITLE: Cardiomyopathy Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Isolated splenomegaly has a prevalence of 2% in USA. Etiologies include congestive, infiltrative, immune, and neoplastic. Congestive splenomegaly occurs due to portal hypertension (PHTN) or thrombosis. Alcohol causes a dose-dependent dilated cardiomyopathy, hematopoietic, and granulopoietic stem cell suppression. CASE PRESENTATION: A 49 year-old male with a history of alcoholic cardiomyopathy (ACM) and HCV presented with shortness of breath and anasarca. Vitals demonstrated tachycardia. Physical exam was significant for pitting edema to the upper chest wall with a palpable, non-tender, mobile spleen tip. Platelets were 124 B/L with unremarkable LFTs and INR. Echocardiogram demonstrated an EF of 15%. A bumetanide infusion was required for diuresis. He developed pancytopenia with nadirs of HGB 10.6 g/dL, PLT 77 B/L and WBC 1.5 B/L. US doppler of the abdomen showed ascites and splenomegaly with hepatic vein dilation of 1.2 cm. CT abdomen with contrast redemonstrated US abdomen findings, without cirrhosis, vascular abnormalities or lymphadenopathy. A negative infectious workup included blood cultures, serologies for EBV, CMV, HIV, and parasite smear. Hematologic workup showed iron-deficiency anemia (IDA) with normal reticulocyte count, B12, folate, haptoglobin, and LDH. Blood smear was negative for morphology suggesting myelodysplastic syndrome, hematologic malignancy, or immune thrombocytopenia. Outpatient elastography was negative for cirrhosis. The patient was diagnosed with pancytopenia secondary to congestive splenomegaly from severe ACM and alcoholic myelosuppression. DISCUSSION: Splenomegaly is diagnosed by a palpable spleen or by imaging. Initial workup should include a CBC to evaluate for abnormal WBCs to rule out myeloproliferative disorders. Biopsy of bone marrow, lymph nodes, or a flow cytometry can reveal malignancy. Infectious workup should test for EBV, CMV, parasitemia, HIV, blood cultures, and other serologies if appropriate. US venous doppler and MRA assist in diagnosing vascular or primary splenic lesions. Splenectomy and pathologic evaluation remain gold-standard for diagnosis of isolated splenomegaly. Evaluation of pancytopenia includes blood smear, iron studies, ESR, CRP, LFTs, reticulocyte count, LDH, direct Coombs test, and evaluation for drug interactions. The spleen can swell eight to ten times its size, resulting in platelet sequestration and WBC phagocytosis. Alcohol causes dose-dependent myelosuppression, concurrently impairing leukocyte development, and chemotaxis. CONCLUSIONS: In the absence of positive infectious, immune, neoplastic and hepatic pathology, this patient’s splenomegaly is likely the result of his severe ACM. While congestive splenomegaly is typically associated with portal hypertension, this rarely occurs without concurrent cirrhosis. Splenomegaly typically affects platelets and WBC but alcoholic myelosuppression and concurrent IDA caused his anemia. Reference #1: Chapman J, Bansal P, Goyal A, Azevedo AM. Splenomegaly. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2021. PMID: 28613657. Reference #2: Ballard HS. The hematological complications of alcoholism. Alcohol health and research world. 1997;21(1):42-52. https://www.ncbi.nlm.nih.gov/pubmed/15706762. Reference #3: Manappallil RG. Acute onset pancytopenia following alcohol heavy drinking. Asian Journal of Bio-Medical Research. Apr-Jun. 2016;2(2). DISCLOSURES: No relevant relationships by Sameer Akhtar No relevant relationships by Sean Coulson No relevant relationships by Brian Thomas No relevant relationships by Rohan Umrani No relevant relationships by Yvette Wang