A 54-year-old man comes to the emergency department after an episode of bloody vomiting. He has had no fever, chills, abdominal pain, diarrhea, or constipation. The patient has a history of alcohol abuse with multiple previous hospital admissions due to alcohol withdrawal and generalized tonic-clonic seizures. He also has a history of intravenous drug abuse and is currently enrolled in a methadone maintenance program. Blood pressure is 96/62 mm Hg and pulse is 102/min. On examination, the patient appears comfortable but develops dizziness when asked to sit up. There is no jugular venous distension. The abdomen is distended with dullness to percussion at both flanks. The liver is enlarged on palpation, and the tip of the spleen is also palpable. There is trace pedal edema. Laboratory studies show: Histopathologic examination of this patient's spleen is most likely to show which of the following?

Question

A 54-year-old man comes to the emergency department after an episode of bloody vomiting.  He has had no fever, chills, abdominal pain, diarrhea, or constipation.  The patient has a history of alcohol abuse with multiple previous hospital admissions due to alcohol withdrawal and generalized tonic-clonic seizures.  He also has a history of intravenous drug abuse and is currently enrolled in a methadone maintenance program.  Blood pressure is 96/62 mm Hg and pulse is 102/min.  On examination, the patient appears comfortable but develops dizziness when asked to sit up.  There is no jugular venous distension.  The abdomen is distended with dullness to percussion at both flanks.  The liver is enlarged on palpation, and the tip of the spleen is also palpable.  There is trace pedal edema.  Laboratory studies show:  Histopathologic examination of this patient's spleen is most likely to show which of the following?

Quizplus · Accepted Answer

This patient with a history of significant alcohol and intravenous drug abuse has evidence of alcoholic liver disease (ALD). His hematemesis, orthostatic symptoms, and normocytic anemia are likely due to acute bleeding from esophageal varices. Although chronic gastrointestinal blood loss can cause microcytic anemia due to depletion of iron stores and reduced hemoglobin synthesis, acute hemorrhage (as in this patient) is usually associated with normal mean corpuscular volume. ALD also causes thrombocytopenia due to decreased platelet production, increased destruction, and splenic sequestration. Fibrosis and distortion of intrahepatic vasculature in ALD obstructs blood flow through the liver, leading to portal hypertension. Because the splenic vein is part of the portal circulation, any condition that causes portal hypertension can lead to splenomegaly with congestive hypersplenism. Venous congestion causes apparent expansion of the red pulp of the spleen, which is composed of blood-filled sinuses and cords lined by reticuloendothelial-type cells. (Choice A) Extramedullary hematopoiesis results when hematopoietic precursor cells are displaced from the bone marrow and infiltrate the liver and spleen preferentially, resulting in splenomegaly. A common condition in which this occurs is myelofibrosis. (Choices B and D) Histiocytic proliferation can cause splenomegaly in the setting of Langerhans cell histiocytosis (formerly known as histiocytosis X), but this is a rare disease with highest incidence in childhood. Metastatic tumors (eg, lung, breast, colorectal cancer) can infiltrate the spleen and lead to hypersplenism, but this patient has no history of malignancy. Given this patient's substance abuse history, ALD is much more likely. (Choice C) Lymphoid follicle expansion can cause hypersplenism in the setting of systemic infections (eg, infectious mononucleosis) or as a result of immunologic diseases (eg, systemic lupus erythematosus, rheumatoid arthritis [Felty syndrome]). Educational objective: Portal hypertension, as seen in alcoholic liver disease, produces splenomegaly by causing congestion of blood within the spleen, which produces expansion of the red pulp.

A 54-Year-Old Man Comes to the Emergency Department After an Episode