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Paediatric wandering spleens in Malawi.

We describe two paediatric cases in which the diagnosis of torsion of a wandering spleen was delayed. To the best of our knowledge, these are the first cases to be described in Malawi, and highlight the importance of accurate ultrasonography in the work up and differential diagnosis of children presenting with an abdominal mass in Sub-Saharan Africa. 
 
Case I 
An 11-year-old male presented with a two-month history of abdominal pain and wasting and a one-month history of abdominal distension. He was otherwise fit and well with no significant past medical or family history. He was on no medications and had no known allergies. 
 
On examination he was wasted with a weight of 19 kilograms. His abdomen was moderately distended with a huge tender mass extending from the right upper quadrant to the right lower quadrant. 
 
A Fine Needle Aspiration, Full Blood Count, Hepatitis B Serology, Stool and Urine Culture and Microscopy, Bone Marrow Aspiration and Ultrasonography of the abdomen were performed. Ultrasonography reported a large mass 10 X 20 cm, with normal liver, pancreas and kidneys. 
 
The working diagnosis was Burkitts Lymphoma and he was commenced on Cyclophosphamide. 
 
Unfortunately the fine needle aspiration was inconclusive and he did not respond to chemotherapy. He was taken to theatre for a laparotomy where a diagnosis of torsion of a wandering spleen was made (See Figure 1). The splenic artery was thrombosed and a splenectomy was performed. The child made an uneventful postoperative recovery and was discharged home on monthly benzathine penicillin prophylaxis. 
 
 
 
Figure 1 
 
 
 
 
Case II 
An eight year old girl was referred from a district hospital with a one year history of abdominal distension. On further questioning she admitted to recurrent episodes of abdominal pain that had prevented her from attending school. At the referring hospital she had been given quinine and a blood transfusion, as her haemoglobin was only 3.7 g/dL. She had no other significant past medical history or family history. She was on no other medications and had no known drug allergies. 
 
On examination she had a firm tender mass in the right upper quadrant but no other organomegaly was noted. Ultrasonography reported a large central well delineated solid mass and normal liver, pancreas and kidneys. The spleen was reported as being difficult to visualise, possibly small. 
 
A fine needle aspiration suggested a mixed inflammatory background and was suspicious of malignancy and a repeat specimen was requested. 
 
The working diagnosis was Burkitts lymphoma and she was commenced on cyclophosphamide whilst undergoing further investigations. 
 
She responded poorly to chemotherapy and a repeat ultrasonogram showed little change in the size of the mass and asplenia. She was taken to theatre with the suspicion of a torted wandering spleen and this was confirmed at laparotomy when a necrotic spleen was removed. She made an uneventful post operative recovery and was discharged home on monthly benzathine penicillin prophylaxis.