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Thoracic splenosis

Case contributed by Moustafa Naglah
Diagnosis probable

Presentation

Increasing dyspnea for one year, worse following recent URTI. Productive cough. Crackles heard on auscultation. Ex-smoker.

Patient Data

Age: 75 years
Gender: Male
x-ray

Multiple healed left rib fractures.

Reticular opacities predominantly in both lower zones likely due to interstitial lung disease.

A 24 mm round opacity seen through the heart shadow suggests lung nodule, possible malignancy.

Probable small left pleural effusion.

T9 vertebral body height reduced.

ct

Review of previous reports revealed a history of a major accident 20 years ago requiring surgery. Ultrasound performed some years afterwards noted a small rounded spleen measuring 6.6 cm.

The current CT show evidence of left diaphragmatic surgical repair as well as multiple healed left rib fractures.

There is nodular thickening of the left lower pleura extending superiorly from the diaphragm and reaching up to 3.6 cm in thickness. Attenuation and enhancement are homogeneous and equal to that of the spleen.

High attenuation within the left diaphragm may be due to calcification or surgical repair.

No pleural effusion noted. Minimal right-sided pleural thickening.

A background of widespread interstitial pulmonary fibrosis and lobular air trapping.

Mildly enlarged right hilar lymph nodes. Small mediastinal lymph nodes.

Small rounded spleen noted measuring 6.5 cm in diameter.

T8 and T10 vertebral compression fractures.

PET CT

Nuclear medicine

The nodular left pleural thickening has an SUV max of 2.1 which is less than the mediastinal blood pool at 2.4. Similar FDG uptake occurred in the splenic remnant.

The right hilar node has an SUV max of 3.5. The subcarinal node has an SUV max of 3.3. These may be related to the interstitial lung disease which shows mild avidity up to 2.2.

Enlarged left lobe of the liver but no abnormal uptake.

Splenunculus in the left upper quadrant.

Case Discussion

Evidence of prior trauma involving the spleen and diaphragm with possible diaphragmatic repair.

The nodular left basal pleural thickening shares imaging characteristics with the splenic remnant. Given the history there is a high probability of thoracic splenosis, a rare benign condition due to heterotopic autotransplantation and implantation of splenic tissue.

FDG PET-CT can help to differentiate splenosis from hypermetabolic intrathoracic tumors such as mesothelioma, neurogenic tumors or pleural metastases. However if available, a technetium-99m sulphur colloid scan is diagnostic because the colloid is phagocytosed by the reticuloendothelial system.

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