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 Introduction:
Spontaneous rupture of the Spleen is a rare and potentially fatal condition. It can occur without history of trauma in a pathological Spleen due to a variety of disease conditions. Recent literature review by Giagoundis et al, identified 136 cases of pathologic rupture of the spleen since 1861; this reflects the rarity of the condition.
Case Report:
A Thirty-two year old male Srilankan
patient presented to the Emergency
Department (ED)
of Hamad General Hospital complaining
of fever for one week duration, associated
with generalized body aches and weakness.
On the day of admission the patient started
complaining from vague upper abdominal
pain and vomited once. There was no history
of trauma.
On examination, the patient looked ill,
pale, and slightly jaundiced. Abdominal
examination showed slightly distended
abdomen, with tenderness and guarding.
His initial vital signs were as follows:
Temperature- 36.1 °C, Pulse rate -101/min,
Respiratory rate-20/min, Blood Pressure-
90/70 mmHg.
Initial Lab. Works were :
Complete Blood Count- WBC 9.4X109/lit,
HGB- 11.2 gm/ dl, HCT- 34.5%, MCV -87.5
fl, Platelets- 44.9x1Q9/lit.
Blood film for malaria- positive for ring
forms and trophozoites of P. Vivax
Urea and Electrolytes: Urea- 7.6 mmol/lit,
Serum Creatinine- 170umol/lit, Serum Bilirubin-28umol/lit.
Erect and Supine Plain X- ray of abdomen
showed no abnormality.
He was started on intravenous fluids and
admitted to the Intensive Care Unit where
he developed further drop of hemoglobin
down to 5.6 gm/dl, in which an emergency
bedside abdominal ultrasonography was
done that showed free fluid around the
liver, spleen, para-colic gutters, and
pelvic areas. Ultrasound guided aspiration
of the peritoneal fluid revealed hemolized
blood. CT scan of the abdomen was done
which showed large blood clot between the
stomach and the spleen with free fluid
at the peri-hepatic and para-colic gutters
and within the pelvis.
In view of the clinical picture, malarial
infection with fever and shock, and the
CT appearance of the spleen, splenic rupture
was considered. The Patient was taken
to the theatre, a laporatomy was performed
with the following findings: blood clots
and free blood in the peritoneum, a mildly
enlarged spleen with a bleeding tear in
the upper (medial) end of the splenic hilum
about 10 cm long. Splenectomy was performed
and sent for histopathology which revealed
a spleen weighing 306 gm, measuring 16x9x2
cm, with a grayish smooth external surface
and a non-encapsulated fragmented area
measuring 12x6 cm. Microscopic examination
showed infiltration of the cords and the
sinusoids with lymphocytes, monocytes
and numerous clusters of neutrophils,
parenchymal hemorrhage with areas of hematoma
from the rupture.
The patient was given antimalarial therapy,
pneumovaccine and was discharged from
the hospital 10 days after surgery in
good general condition.
Discussion:
Spontaneous rupture of a pathologic spleen
is a rare condition, but should always
be borne in mind. Rapid evaluation of
the hypotensive patient in the ED is essential,
availability of ultrasonography in the
ED, performed by emergency physicians
and surgeons has a role in diagnosis,
treatment, and outcome.2,3.
This complication has been reported in
a variety of clinical conditions, it is
an uncommon complication of various infectious
diseases, such as P. vivax malaria, but
it has also been reported in Pialciparum
malaria ,the total number of reported
cases of spontaneous splenic rupture in
malaria was 11 cases in the English -language
literature from 1960-1991, most are associated
with Plasmodium Vivax 4,5,6. Besides it
is a well known rare complication of Infectious
Mononucleosis, which can be fatal 7; A
case was reported with Varicella zoster
infection 8.
Spontaneous rupture of the spleen is a
rare complication of Q- fever infection,
only two cases have been reported 9, besides
it is a rare, but known complication during
Typhoid fever 8; it has also been reported
with Primary Cytomegalovirus infection 11.
A variety ofhaematological conditions
were associated with spontaneous rupture
of the spleen, it was reported as the
initial manifestation of Acute Lymphoblastic
Leukemia 1,12. It has also been reported
with Chronic Myeloid Leukemia l3,Plasma
Cell Leukemia l4,Hodgkin and Non Hodgkin
Lymphomas 15,16.
It has also been reported in a variety
of miscellaneous conditions: It was an
unususal presentation of Primary Amyloidosis
17, and of an Amyloid spleen in a patient
with continuous ambulatory peritoneal
dialysis 16, it was also reported in a
patient with severe Pre-eclampsia 19,
and during peripheral blood stem cell
mobilisation in a healthy donor 18, and
in a patient with Deep venous thrombosis
on prophylactic subcutaneous Heparin therapy,
which described both a previously indescribed
complication of subcutaneous Heparin therapy
and a failure of ultrasound diagnosis
2l.and last but not least spontaneous
rupture of normal spleen was reported,
which is the second case of its kind since
1958 and the first ever from the Indian
subcontinent 22.
References:
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