Spontaneous Splenic Rupture as the First Manifestation of Infectious Mononucleosis: A Review of Published Cases
DOI:
https://doi.org/10.5281/zenodo.22279571Keywords:
Infectious mononucleosis, Splenic rupture, Epstein-Barr virus, Splenectomy, Return to playAbstract
Background: Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis (IM), caused by
Epstein-Barr virus, and can occur without trauma or, occasionally, before any other IM symptom is recognised.
Objective: To review published case reports, case series and pooled analyses of spontaneous splenic rupture as the presenting
feature of IM. Methods: Narrative review of case reports, systematic reviews, retrospective cohorts and sports-medicine position statements. Findings: Pooled series describe 85-186 cases, 86-91% atraumatic, rupturing a median of 8-11.5 days (mean 14-15.4 days) after symptom onset, occasionally extending to 8 weeks. The only denominator-based incidence estimate is 0.062-0.111% among 8,116
IM patients. Splenectomy has historically predominated (66-84%), but a consecutive cohort achieved 90% non-operative success
with zero mortality, against 4.8-9% mortality in pooled case reports, likely reflecting publication bias toward severe presentations.
Conclusions: Non-operative management is increasingly favoured when haemodynamically feasible; return-to-sport guidance
remains low-grade evidence and should prioritise symptom education over fixed ultrasound thresholds.
References
Rutkow, I.M. (1978) Rupture of the spleen in infectious mononucleosis: a critical review. Archives of Surgery, 113(6): 718-720.
Asgari, M.M., Begos, D.G. (1997) Spontaneous splenic rupture in infectious mononucleosis: a review. Yale Journal of Biology and Medicine, 70(2): 175-182.
Bartlett, A., Williams, R., Hilton, M. (2016) Splenic rupture in infectious mononucleosis: a systematic review of published case reports. Injury, 47(3): 531-538.
Toti, J.M.A., Gatti, B., Hunjan, I., Kottanattu, L., Fare, P.B., Renzi, S., et al. (2023) Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review. Swiss Medical Weekly, 153(5): 40081.
Sylvester, J.E., Buchanan, B.K., Paradise, S.L., Yauger, J.J., Beutler, A.I. (2019) Association of splenic rupture and infectious mononucleosis: a retrospective analysis and review of return-to-play recommendations. Sports Health, 11(6): 543-549.
Stockinger, Z.T. (2003) Infectious mononucleosis presenting as spontaneous splenic rupture without other symptoms. Military Medicine, 168(9): 722-724.
Gayer, G., Zandman-Goddard, G., Kosych, E., Apter, S. (2003) Spontaneous rupture of the spleen detected on CT as the initial manifestation of infectious mononucleosis. Emergency Radiology, 10(1): 51-52.
Coppola, A., Apostolou, M., Delle Donne, H.D., Ferrante, P., Bagnoli, P.F. (2026) Atraumatic splenic rupture as the sole manifestation of infectious mononucleosis: a case report and literature review. Cureus, 18(3): e105885.
Gavriilidis, P., Xanthakos, P. (2024) A rare complication of atraumatic splenic rupture in infectious mononucleosis: a case report. British Journal of Hospital Medicine, 85(11): 1-9.
Wilson, G.G., Rennie, K. (2025) Case report of a splenectomy secondary to infectious mononucleosis in a 16-year-old female. Journal of Surgical Case Reports, 2025(6): rjaf420.
Farley, D.R., Zietlow, S.P., Bannon, M.P., Farnell, M.B. (1992) Spontaneous rupture of the spleen due to infectious mononucleosis. Mayo Clinic Proceedings, 67(9): 846-853.
Luzuriaga, K., Sullivan, J.L. (2010) Infectious mononucleosis. New England Journal of Medicine, 362(21): 1993-2000.
Dunmire, S.K., Verghese, P.S., Balfour, H.H. (2018) Primary Epstein-Barr virus infection. Journal of Clinical Virology, 102: 84-92.
Aubrey-Bassler, F.K., Sowers, N. (2012) 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emergency Medicine, 12: 11.
Balfour, H.H., Odumade, O.A., Schmeling, D.O., Mullan, B.D., Ed, J.A., Knight, J.A., et al. (2013) Behavioral, virologic, and immunologic factors associated with acquisition and severity of primary Epstein-Barr virus infection in university students. Journal of Infectious Diseases, 207(1): 80-88.
Dommerby, H., Stangerup, S.E., Stangerup, M., Hancke, S. (1986) Hepatosplenomegaly in infectious mononucleosis, assessed by ultrasonic scanning. Journal of Laryngology and Otology, 100(5): 573-579.
Hosey, R.G., Kriss, V., Uhl, T.L., DiFiori, J., Hecht, S., Wen, D.Y. (2008) Ultrasonographic evaluation of splenic enlargement in athletes with acute infectious mononucleosis. British Journal of Sports Medicine, 42(12): 974-977.
Sweeney, P., McKevitt, K., Ni Mhuircheartaigh, J., Abdeldaim, Y. (2026) Spontaneous atraumatic splenic rupture secondary to infectious mononucleosis. Irish Medical Journal, 119(2): 32.
Owies, A., Attia, A., Cepeda, P., Dixon, J.J. (2025) Spontaneous splenic rupture due to infectious mononucleosis requiring splenectomy: clinical challenges and management. BMJ Case Reports, 18(5): e264789.
Sogiawalla, R., Raj, J.P., Sogiawalla, F. (2026) Spontaneous splenic rupture without trauma: clinical insight from a three-case series. Journal of Emergencies, Trauma, and Shock, 19(2): 103-106.
Longi, A.A., Edakkavil, Z., Fazlani, M., Rajesh, N., Quraishi, M.O. (2025) Splenic rupture in infectious mononucleosis: a case report. Cureus, 17(5): e83438.
Hosey, R.G., Mattacola, C.G., Kriss, V., Armsey, T., Quarles, J.D., Jagger, J. (2006) Ultrasound assessment of spleen size in collegiate athletes. British Journal of Sports Medicine, 40(3): 251-254.
McCorkle, R., Thomas, B., Suffaletto, H., Jehle, D. (2010) Normative spleen size in tall healthy athletes: implications for safe return to contact sports after infectious mononucleosis. Clinical Journal of Sport Medicine, 20(6): 413-415.
O'Connor, T.E., Skinner, L.J., Kiely, P., Fenton, J.E. (2011) Return to contact sports following infectious mononucleosis: the role of serial ultrasonography. Ear, Nose and Throat Journal, 90(8): E21-E24.
Munzi, G., Casella Mariolo, J.R., Poillucci, G., Iodice, A., Rossi, L., Serao, A. (2025) A spontaneous splenic rupture secondary to Epstein Barr virus infection: a case report. International Journal of Surgery Case Reports, 133: 111609.
McQueen, R.G., Harwick, E., Branchford, B., Densmore, J.C. (2025) Nonoperative management of infectious mononucleosis-associated splenic rupture: a case report. WMJ, 124(4): 385-388.
Putukian, M., McGrew, C.A., Benjamin, H.J., Hammell, M.K., Hwang, C.E., Ray, J.W., et al. (2023) American Medical Society of Sports Medicine position statement: mononucleosis and athletic participation. Clinical Journal of Sport Medicine, 33(4): 359-367.
Renzulli, P., Hostettler, A., Schoepfer, A.M., Gloor, B., Candinas, D. (2009) Systematic review of atraumatic splenic rupture. British Journal of Surgery, 96(10): 1114-1121.
