Patient Presentation
An almost 18-year-old female came to clinic ostensibly for weight management with approval from her parent. She said she did little exercise preferring to play video games, and continued to have poor nutritional intake. “I just want the shot. My aunt started on them and she’s lost a lot of weight. I just want to do that too,” she said.

The past medical history showed her to have increasing weight over the past few years with a body mass index (BMI) of 28.6 kg/M the previous year. Appropriate nutrition and activity and healthy lifestyles had been discussed over several years and followup appointments including referral to the cardiometabolic clinic had not been kept. Her lab testing the previous year showed mildly elevated liver function tests, low HDL and elevated LDL on lipid testing, and an HgbA1c of 5.9 %. Her thyroid testing was normal.

The family history was positive for obesity, type 2 diabetes, and heart disease. The review of systems revealed that she endorsed tiredness with additional exercise, no problems with sleeping, headache, abdominal pain, or joint problems.

The pertinent physical exam had a heart rate of 84, blood pressure of 118/76, with normal respirations and temperature. Her height was 165 cm, weight 80.8 kg with a BMI of 29.7 kg/M. She had no evidence of acanthosis nigricans, but had striae. Her thyroid was normal, heart was without murmurs and lungs were clear. Her abdomen was obese making it difficult to tell if there was any organomegaly. The rest of her examination was normal.

The diagnosis of continued elevation in body mass and serious obesity. The pediatrician discussed healthy lifestyle again along with referral to the cardiometabolic clinic for weight management including possible medication management. The adolescent asked, “Aren’t you going to give me the shots?” and when the pediatrician said that he would not be, the adolescent said “I just want the shots and I’m not going to do any exercise, or do anything else.” The pediatrician tried to re-engage with the adolescent, but she would not re-engage. As she left, he reminded her of her health maintenance visit that was due in 4 months and the issue could be discussed at that time as well.

Discussion
Overweight and obesity are health problems that are increasing with a 1 in 5 prevalence of pediatric obesity. Data from 2017-20 estimated that 19.7% of US children were obese, and “[o]ne study estimated that about 57% of the population of US children in 2016 would live with obesity by the time they were aged 35 years.” Multiple studies have shown that overweight and obese children have a high likelihood of becoming obese adults. They are more likely to have “type 2 diabetes mellitus…, hypertension, hyperlipidemia, metabolic-dysfunction-associated steatotic liver disease…., and obstructive sleep apnea, among other conditions.” Pediatric and adolescent mental health can also be affected with “…increased risk of anxiety, depression, social isolation, and peer victimization.””

Obesity management takes a multidisciplinary approach including nutritional counseling, increased activity, mental health support, and potential medication and surgical interventions (i.e. bariatric surgery). Glucagon-like peptide-1 receptor agonists (GLP-1s) are similar to a type of gut-derived hormone which help with regulating metabolism though “…increased insulin secretion and sensitivity to delayed gastric emptying and promotion of postprandial satiety.” GLP-1s (e.g. exenatide, dulaglutide, liraglutide, tirzepatide, semalutide) were approved for type 2 diabetes for about 20 years, and for weight management for about 10 years. Semaglutide (Wegovy® Ozempic®) was approved for adults in 2017 for type 2 diabetes, in 2021 for weight management and for lowering the risks of cardiovascular problems in 2024. GLP-1 cost can be significant ranging $500-1600/month depending on the medication, dose and potential insurance coverage.

Learning Point
The use of GLP-1s is quickly and significantly expanding in the adult population and already changes are seen in the adolescent and young adult populations.

One 2024 study found that dispensing of GLP-1s significantly increased from 2020-2024 for adolescents and young adults ages 12-25 years. For adolescents (12-17 years) the number of prescriptions is substantially lower (N=30,947) than for young adults (18-25 years, N=162,439). About 46% of the prescriptions were dispensed in the US South, and the last GLP-1 dispensed was most commonly semaglutide. For both groups the most common prescribers were endocrinologists, nurse practitioners and family medicine physicians. Pediatricians prescribed 3415 prescriptions for adolescents and 2067 for young adults, or ~2.8% of all prescriptions. The American Academy of Pediatrics State of the Art Review noted that “[GLP-1] are relatively new and expensive, and initiating treatment typically requires subspecialty and/or multidisciplinary care.”

A 2021 meta-analysis for children and adolescents < 18 years found that GLP-1s were "...safe and effective in modestly reducing weight, BMI and glycated hemoglobin A1c, and systolic blood pressure in children and adolescents with obesity in a clinical setting...." Nausea was a common side effect. Lifestyle interventions amplified the weight-reducing effects of GLP-1s in the pediatric age group.

Currently Federal Drug Administration approved GLP-1s in pediatric age range are liraglutide injected daily for patients 10 years and older for type 2 diabetes since 2019, with generic approval in 2024. It is also used for patients 12 years and older for severe obesity since 2020 with a BMI of > 30 kg/M and weight more than 60 kg. Semaglutide, as Wegovy®, is injected weekly and was approved for patients 12 years and older for obesity in 2022.

Because of the GLP-1 use expansion and significant costs, the FDA recently is warning about unapproved GLP-1s being used for weight loss.

Questions for Further Discussion
1. What are your current practices and planned future practices for GLP1s?
2. What are indications for use of metformin? A review can be found here
3. How do you manage other obesity-related problems such as hypertension?

Related Cases

Disease: Obesity

Symptom/Presentation: Obesity

Specialty: Endocrinology | General Pediatrics | Pharmacology / Toxicology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for this topic: Obesity

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

FDA approves weight management drug for patients aged 12 and older. December 4, 2020. Accessed August 4, 2025. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-weight-management-drug-patients-aged-12-and-older

Ryan PM, Seltzer S, Hayward NE, Rodriguez DA, Sless RT, Hawkes CP. Safety and Efficacy of Glucagon-Like Peptide-1 Receptor Agonists in Children and Adolescents with Obesity: A Meta-Analysis. J Pediatr. 2021;236:137-147.e13. doi:10.1016/j.jpeds.2021.05.009

Cardiometabolic Health Congress. In the first big pharmaceutical development of 2023, Novo Nordisk announced that the U.S. Food and Drug Administration (FDA) has approved an expanded indication for semaglutide as the first injectable antiobesity prescription medication for use in pediatric patients. January 6, 2023. Accessed August 4, 2025. https://www.cardiometabolichealth.org/article/fda-approves-semaglutide-for-pediatric-patients/

Lee JM, Sharifi M, Oshman L, Griauzde DH, Chua KP. Dispensing of Glucagon-Like Peptide-1 Receptor Agonists to Adolescents and Young Adults, 2020-2023. JAMA. 2024;331(23):2041-2043. doi:10.1001/jama.2024.7112

Commissioner of the FDA Approves First Generic of Once-Daily GLP-1 Injection to Lower Blood Sugar in Patients with Type 2 Diabetes. FDA. December 27, 2024. Accessed August 4, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-generic-once-daily-glp-1-injection-lower-blood-sugar-patients-type-2-diabetes

Stefater-Richards MA, Jhe G, Zhang YJ. GLP-1 Receptor Agonists in Pediatric and Adolescent Obesity. Pediatrics. 2025;155(4):e2024068119. doi:10.1542/peds.2024-068119

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A pediatrician was reviewing the chart of a 26-month old female who had been seen at a local urgent care for sore throat. The patient has been empirically treated with antibiotics based on history and physical examination. The urgent care clinician also cited a modified Centor criteria as justification for starting the empiric antibiotics. She discussed this issue with one of her partners who had noted a similar practice pattern. They identified that it was a new urgent care clinician who had started empiric antibiotics twice. The pediatrician sent a professional e-mail to the urgent care physician providing information that the use of the modified Centor criteria was not appropriate in the < 3 year old age group, and providing a reference to the clinical guidelines. The urgent care provider's reply thanked the pediatrician for the guidance.

Discussion
Group A streptococcal pharyngitis (GAS) is the most common bacterial cause of pharyngitis world-wide. Not only can it cause localized disease, but it can cause invasive disease such as necrotizing fasciitis, pneumonia, and toxic shock syndrome. In children 3 years and older it can cause potential immunological complications such as rheumatic heart disease. GAS is most common in ages 5-15 years, and occurs often in temperate climates, with the highest incidence in winter and early spring.

While GAS is common, its evaluation and management are not simple.

History and physical examination findings cannot adequately discern GAS from the even more common viral causes of infectious pharyngitis (e.g. adenovirus, coxsackie, Epstein-Barr virus, influenza, rhinovirus, etc.) as there is significant overlap. “There needs to be more clarity in the literature regarding the clinical signs and symptoms of viral and bacterial pharyngitis. Symptoms, such as severe sore throat, sudden onset of fever, chills, malaise, nausea, vomiting, abdominal pain, myalgia, headache, tonsillar discharge, tonsillar hypertrophy, tender-enlarged anterior cervical lymphadenopathy, absence of cough, palatal petechia, strawberry tongue, scarlatiniform rash, and uvula edema may be observed in streptococcal infections….Although the presence of cough, runny nose, congestion, hoarseness, mouth ulcers, conjunctivitis, and diarrhea are more suggestive of a viral infection, the clinical symptoms seen in streptococcal infections can also be seen in viral infections.”

A throat culture is the gold standard for diagnosis but can take 1-2 days before results are available, and testing may be limited in some locations. Rapid antigen detection tests (RADT) can be completed in the office and are quick to perform. Cost can still be a problem in resource limited areas.

Learning Point
The appropriate use of RADT along with clinical decision support algorithms and clinical practice guidelines can help clinicians make good decisions regarding patient care. They do need to be applied to the appropriate patient population.

The Centor criteria and McIssac criteria (MCC) are two clinical decision support tests which can be used to help a clinician. Centor scores for patients > 15 years and MCC for patients > 3 years were validated by Fine et. al. The Infectious Disease Society of America (IDSA)has clinical practice guidelines for clinical use.

• Centor criteria (1 point for each criteria present, range is 0-4 points)
  • Exudate or swelling of tonsils
  • Swollen/tender anterior cervical lymph nodes
  • Fever
  • Absent cough
• Modified McIssac criteria (modified Centor criteria or MCC, range 0-5 points). The following is added to the Centor criteria
  • Ages 3-14 years = +1 point
  • Ages 15-44 years = 0 point
  • Ages > and = 45 years = -1 point

In general, scores of 0-1 do not recommend additional testing or treatment, a score of 2 and a clinician may consider testing, and scores of 3 or more suggest testing would be indicated.

Children under 3 years are less likely to have GAS and also the immunological sequelae or rheumatic heart disease are rare. They also are more likely GAS carriers and may test falsely-positive. The Centor and MCC were not developed, nor validated, for this age group. Testing is not recommended for this age group, but testing may be considered if there is a close contact such as a sibling or close day-care contact who is positive for GAS.

Children and youth 5-15 years are at highest risk for GAS. The Centor and MCC can be applied for children 3 years and older as the tests are validated in this age group. Children, youth and adults with overt viral symptoms such as presence of cough, rhinorrhea, hoarseness and oralpharyngeal ulcers are usually not recommended to be tested.

All pediatric patients should have a positive RADT and/or culture for GAS before antibiotics are prescribed, as history and physical examination are unreliable indicators of GAS. Positive RADTs do not need a confirmatory throat culture. Negative RADTs do need a confirmatory culture in children and adolescents, but not adults as the incidence of GAS in the adult population is low and sequelae risk is very low in adults.

Appropriate antibiotics should be prescribed that can eradicate the GAS. Penicillin or amoxicillin for 10 days is the common choice. For allergic individuals “…a first generation cephalosporin …for 10 days, or clindamycin or clarithromycin for 10 days, or azithromycin for 5 days.” The IDSA guidelines has a discussion about empiric treatment in adult patients which balances the risk of over- and under-treatment. They state “…exclusion of the diagnosis [of GAS] on the basis of negative RADT results without confirmation by negative culture results is an acceptable alternative to diagnosis….The generally high specificity of RADT should minimize overprescription of antimicrobials for treatment of adults.”

Questions for Further Discussion
1. What causes pharyngitis? A review can be found here
2. How is invasive streptococcal disease treated?
3. What are the common serotypes for Group B streptococcus? A review can be found here

Related Cases

Disease: Streptococcal Infections | Throat Disorders

Symptom/Presentation: Infections | Sore Throat

Specialty:Infectious Diseases | Pathology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Streptococcal Infections and Strep Throat.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e86-e102. doi:10.1093/cid/cis629

Fine AM, Nizet V, Mandl KD. Large-Scale Validation of the Centor and McIsaac Scores to Predict Group A Streptococcal Pharyngitis. Arch Intern Med. 2012;172(11):847-852. doi:10.1001/archinternmed.2012.950

Jaaskelainen J, Renko M, Kuitunen I. Centor scores associated poorly with rapid antigen test findings in children with sore throat. Eur J Pediatr. 2024;184(1):4. doi:10.1007/s00431-024-05863-2

Haynes MA, Temkit M, Kushner I, Hindman DE. Appropriateness of Use of Streptococcal Pharyngitis Testing and Associated Antibiotic Prescribing in the Urgent Care Setting. Clin Pediatr (Phila). 2024;63(12):1691-1697. doi:10.1177/00099228241237908

Eroglu A, Suzan OK, Kolukısa T, et al. The relationship between group A streptococcus test positivity and clinical findings in tonsillopharyngitis in children: systematic review and meta-analysis. Infection. 2025;53(1):427-436. doi:10.1007/s15010-024-02395-7

Leung AKC, Lam JM, Barankin B, Leong KF, Hon KL. Group A beta-hemolytic Streptococcal Pharyngitis: An Updated Review. Curr Pediatr Rev. 2024;21(1):2-17. doi:10.2174/1573396320666230726145436

Author
Donna M. D’Alessandro, MD

Patient Presentation
In clinic the residents were discussing a a 4-year-old female who had recurrent pneumonia. “They figured out that it wasn’t straightforward pneumonia but was a pulmonary sequestration. Surgery removed it and now she is back on the floor after a short PICU stay and is doing well. I have to say that I had to read up again about these. I always get confused with all these lung lesions because the names seem to be so similar. The diagnosis was an extralobar pulmonary sequestration. The one that sort of acts like its own little lobe of the lung with its own pleura and blood supply,” one resident remarked. “I know that this was part of embryology that was harder for me. I have to look these up too. If I remember right she shouldn’t have any long term problems right? If everything goes well with the surgery and her recovery, right?” a second resident said. “Yeah, she should be fine and hopefully this will stop the pneumonias and her being in the hospital,” commented the first resident.

Figure 147 – CXR PA and lateral (above) shows a large round opacity in the left lower lobe posteriorly that abuts the diaphragm. Coronal T1 MRI with contrast of the chest (below) shows a uniformly enhancing mediastinal mass that extends into the retrocrural regions of the chest bilaterally and that has a feeding vessel arising from the aorta.

Discussion
Cystic lung lesions can be confusing because of terminology and overlapping presentations and radiological appearances. Cystic lung lesions in children are usually congenital and benign especially in young children. In older children oncological and genetic causes also should be considered especially if there are multifocal lesions.

Learning Point

• Cysts, Emphysema and Pneumatocoeles
  • Cysts are a gas-filled round parenchymal lesions with thin wall that is < 2 mm in size. Lung cysts are associated with aging especially after age 40.
  • Emphysema is a “permanent enlargement of alveolar spaces with disruption of septa, and compression of surrounding parenchyma.” It is distal to the bronchiole and does not have a wall.
  • Pneumatocoeles are lung spaces that occur after trauma or infection and filled with gas.
• • Disease: Extralobar Pulmonary Sequestration |

    Congenital Cystic Lung Malformations

    • While many of these lesions are found on prenatal ultrasound, they may present only years later with recurrent pneumonia or due to compression of adjacent structures. They have a rare risk of malignant transformation.
    • Incidence is about 2500-8000 live births
    • Treatment depends on presentation and patient age with monitoring, prenatal and post-natal surgical interventions. Asymptomatic lesions may be monitored and possibly surgically treated depending on the lesion type
      • Foregut Duplications and Bronchogenic Cysts
        • Pathology: Occur because of “…anomalous budding of the foregut endoderm from which the respiratory tract and upper gastrointestinal tract develop, as well as other organ systems.”
        • Location: Bronchogenic cysts are most common in the mediastinum around the tracheal bifurcation. Also seen in supra- and sub-diaphragmatic and intraparenchmal locations
        • Appearance: Unilocular without septations
        • Fluid: Mucinous but can be purulent or bloody if there is infection or hemorrhage
        • DDX: Abscess, large cyst congenital pulmonary airway malformation but both of these are multiseptated
        • Presentation: Incidental finding, superimposed infection, compression of adjacent structures causing symptoms
      • Congenital Pulmonary Airway Malformations (CPAMs)
        • Most common lower respiratory tract malformation. Size, histological appearance and blood supply have been used for classification.
        • Occur because of airway obstruction during development.
          • Large Cyst CPAM
            • Appearance: > 2 cm in size, may be multiloculated, usually without a systemic blood supply
            • Fluid: Mucinous and looks like bronchioles without cartilage or glands
            • DDX: Bronchogenic cyst, pulmonary interstitial emphysema, pneumatocoele and pleuropulmonary blastoma (cystic type)
            • Presentation: Prenatal ultrasound finding, hydrops fetalis, compression of adjacent structures, infection
          • Small Cyst CPAM
            • Appearance: < 2 cm in size, usually multiple, uniform cysts, may have blood supply
            • Fluid: Mucoid, dilated bronchiole-like structure
            • DDX: Intralobar sequestration (ILS) and hybrid lesions
            • Presentation: Prenatal ultrasound, neonatal respiratory distress
      • Bronchopulmonary Sequestration
        • Pathology: No connection to tracheobronchial tree and have systemic arterial supply usually from the thoracic or abdominal aorta and venous drainage is through thoracic or systemic veins.
        • Extralobar sequestrations (ELS) have their own pleural lining and lung tissue similar to an accessory lobe. Intralobar sequestrations (ILS) are “non-functioning lung segments embedded within the pleura of the lung lobe in which they arise.””
        • Location: ELS thoracic cavity or infradiaphragmatic often in the left lower thoracic area, ILS are located within the lung.
        • Appearance: ELS looks like bronchi and alveoli with large vessels. ILS looks similar to small cyst CPAM
        • Fluid: Mucoid
        • DDX: Small cyst CPAM, chronic pneumonia
        • Presentation: ELS often has other congenital anomalies, ILS is intraparenchymal lesion, compression of adjacent structures
      • Pulmonary Hyperplasia (PH) and Congenital Lobar Overinflation (CLO)
        • Pathology: PH is caused by overgrowth of pulmonary parenchymal tissue causing airway obstruction in fetal life. CLO is caused by air trapping in the pulmonary lobe
        • Appearance: PH has increased alveolar counts. CLO has alveolar distension and is often in the upper lobe
        • DDX: Small cyst CPAM, true emphysema
        • Presentation: PH prenatal diagnosis with associated fetal hydrops or polyhydramnios . Both PH and CLO can present with compression of adjacent structures causing symptoms
    • Neoplasms
      • Pleuropulmonary Blastoma (PPB)
        • Pathology: most common primary parenchymal lung tumor. Presentation age depends on type with older ages having worse prognosis. Associated with DICER1 gene.
        • Location: peripheral multiloculated cysts that may have hemorrhage in them
        • Appearance: 3 types based on cystic and solid components
        • DDX: CPAMs
        • Presentation: Prenatal diagnosis, respiratory distress, pneumothorax, abdominal mass with some types, systemic symptoms such as fever, malaise
    • Other lesions
      • Birt-Hogg-Dube syndrome
      • Ehler-Danlos syndrome
      • Langerhan cell histiocytosis
      • Lymphangioleiomyomatosis
      • Marfan syndrome

    Questions for Further Discussion
    1. What are indications for more evaluation of recurrent pneumonia?
    2. What evaluation for recurrent pneumonia would you do?
    3. What are causes of respiratory distress? A review can be found here

    Related Cases

    Disease: Extralobar Pulmonary Sequestration | Birth Defects | Respiratory Diseases
    Symptom/Presentation: Frequent or Recurrent Infections
    Specialty: Allergy / Pulmonary Diseases | Radiology / Nuclear Medicine / Radiation Oncology | Surgery
    Age: Preschooler

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Birth Defects and Respiratory Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Cortes-Santiago N, Deutsch GH. Pediatric Cystic Lung Lesions. Surgical Pathology Clinics. 2020;13(4):643-655. doi:10.1016/j.path.2020.07.002

    Hegde BN, Tsao K, Hirose S. Management of Congenital Lung Malformations. Clinics in Perinatology. 2022;49(4):907-926. doi:10.1016/j.clp.2022.08.003

    Valente T, Guarino S, Lassandro G, et al. Cystic lung diseases: radiological aspects. Clin Radiol. 2022;77(5):e337-e345. doi:10.1016/j.crad.2022.01.044

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa

Patient Presentation
A 6-year-old male came to clinic after hospitalization for a bike-automobile accident. He was wearing a bicycle helmet and had an initial Glascow Coma Score of 11 (i.e. responded to speech, moved to pain and used inappropriate words), and was hemodynamically stable. He had 9th and 10th left rib fractures, a left mid-shaft radial fracture, splenic hematoma, and left renal contusion. He had undergone exploratory laparotomy because of inconclusive initial radiological imaging regarding the extent of his abdominal injuries. His intensive care unit course showed him treated with heavy sedation, casting of radial fracture and monitoring. He remained hemodynamically stable and did not require intubation or transfusion. His mentation returned to normal as sedation was decreased. He was discharged after 9 days including 6 in the intensive care unit. Since discharge a visiting nurse had been seeing him and reported normal vital signs, increasing activity and decreasing fatigue, along with decreasing need for pain medications.

The pertinent physical exam showed a tired appearing male with normal vital signs. He had healing bruises and “road rash” mainly on the left side of his body, along with a cast on his left forearm. He had a healing abdominal scar. His left lower ribs were more bruised and sore with palpation. His abdomen had no tenderness except for the area around the incision. The rest of his examination was normal.

The diagnosis of a patient with post-traumatic injuries that were improving was confirmed. The patient’s clinical course showed that he returned to limited activities at 5 weeks post-injury. By 8 weeks he was out of his cast and only complained of intermittent rib pain that required no treatment. Repeated imaging showed resolution of the splenic hematoma and renal contusion, and he also had normal laboratory testing.

Figure 146 – Axial CT with contrast of the abdomen (above) shows multiple areas of low density in the spleen, a perisplenic fluid collection, and (below) a large amount of free fluid in the pelvis.

Discussion
The spleen is an intraperitoneal organ tucked up under the 9-11th ribs by the diaphragm, and is lateral to the left kidney and stomach which it is connected to by parts of the greater omentum. It is a highly vascular organ where the splenic artery arises from the celiac trunk and branches into 5 splenic segmental arteries. The splenic vein combines with the superior mesenteric vein to form the hepatic portal vein. It has an important role in filtering blood, removing old blood cells, assisting regulation of the amount of blood circulating, and in immunoregulation. People can live without a spleen if it is structurally or functionally damaged (e.g. trauma or sickle cell disease). Patients have an increased risk of infections especially encapsulated organisms and need to be expectantly managed with prophylactic antibiotics and vaccination (especially for pneumococcus, meningococcus and influenza).

Splenic injuries are more common in children than adults due to location, relative size and higher transmission rate of forces through the abdominal wall.

Potential splenic problems include:

• Capsular hematoma
  • At risk for capsular rupture
  • Can be “bruised” to severe capsular distension
• Capsular rupture or laceration
• Arterial thrombosis
• Venous thrombosis

Because the spleen is a highly vascular organ, intra-abdominal bleeding can quickly cause shock even with 5-10% of blood volume loss. Signs of splenic rupture include left sided abdominal pain, left shoulder tip pain, abdominal distension and hemodynamic instability such as syncope and hypotension. Non-operative management of splenic injury is preferred. If operative management is needed then more minimal treatment such as embolization is preferred to splenectomy.

Acutely enlarged spleens are more often caused by infections such as Epstein Barr virus and can cause early satiety, left upper quadrant/shoulder pain, and there could be problems with anemia, or platelets. It can be hard to discern an enlarged spleen on physical examination, but palpable fullness or blottable mass (sometimes described as feeling like a water balloon) in the lateral abdomen indicate potential enlargement.

Learning Point
Causes of splenic rupture include:

• Trauma (very common)
• Atraumatic rupture (uncommon)
  • Infection
    • Epstein Barr virus (up to ~70% in some studies as the cause)
    • Cytomegalovirus
    • HIV
    • COVID-19
  • Malignancy
  • Inflammatory disease/non-infection
    • Pancreatitis
    • Cirrhosis
  • Congenital anomalies

Questions for Further Discussion
1. With Epstein Barr virus and splenic enlargement, when can a patient return to sports?
2. What are presentations of Epstein Barr virus? A review can be found here
3. At what age are patients with sickle cell disease considered functionally asplenic?
Related Cases

Disease: Spleen Diseases | Abdominal Pain

Symptom/Presentation: Trauma

Specialty: Critical Care | Surgery | Radiology / Nuclear Medicine / Radiation Oncology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Spleen Diseases

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Dixon S, Horgan LF. The elusive spleen. Ann R Coll Surg Engl. 2019;101(3):176-179. doi:10.1308/rcsann.2018.0215

Grootenhaar M, Lamers D, Ulzen KK van, de Blaauw I, Tan EC. The management and outcome of paediatric splenic injuries in the Netherlands. World Journal of Emergency Surgery. 2021;16(1):8. doi:10.1186/s13017-021-00353-4

Bakalli I, Biqiku M, Cela D, et al., Atraumatic splenic rupture in a child with COVID 19. BMC Pediatrics 2022;22:300. Accessed June 9, 2025. https://pubmed-ncbi-nlm-nih-gov.proxy.lib.uiowa.edu/35597923/

Schwartz K, Krishnasarma R, Snyder E, et al. Spontaneous splenic rupture in a neonate: a case report and literature review. Emerg Radiol. 2024;31(1):117-122. doi:10.1007/s10140-024-02199-0

Spleen problems and spleen removal. NHS.uk. October 18, 2017. Accessed June 9, 2025. https://www.nhs.uk/tests-and-treatments/spleen-problems-and-spleen-removal/

The Spleen – Position – Structure – Neurovasculature – TeachMeAnatomy. Accessed July 15, 2025. https://teachmeanatomy.info/abdomen/viscera/spleen/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa