Systematic review of atraumatic splenic rupture

Sudden abdominal pain in a patient with pneumonia reveals spontaneous splenic rupture in normal sized spleen

Splenic rupture is a life-threatening condition that is most frequently of traumatic etiology. Atraumatic or spontaneous splenic rupture is much rarer and less frequently reported. We present a case of an 84-year-old male patient initially hospitalized for pneumonia, who developed sudden abdominal pain and hemodynamic instability. Further investigations revealed a spontaneous splenic rupture. Histopathological examination postsplenectomy identified a splenic hamartoma, which had not been visualized on prior imaging studies.

Atraumatic Splenic Rupture Unveiling Mumps With an Underlying B-cell Lymphoid Hyperplasia: A Diagnostic Conundrum

Atraumatic splenic rupture (ASR) is an unfamiliar entity that is potentially life-threatening if there is a delay in the diagnosis. Due to its rarity and its non-specific presentation, it can be a challenge to diagnose early. In this report, we present a case of a 42-year-old male patient who presented to the emergency department with nonspecific abdominal pain and had no past medical history. The patient presented abdominal pain associated with nausea, vomiting, and sweating. On examination, the patient was found to be tachycardic and mildly hypotensive, with mild left upper quadrant tenderness, and a lactate of 4 mmol/L on venous blood gas analysis. He was urgently transferred to the resuscitation area, where resuscitation commenced. Further investigations revealed significant anemia. The contrast-enhanced CT of the abdomen performed revealed a 13-cm splenic hemostasis suggestive of non-traumatic splenic rupture. The patient lacked any history of blunt trauma or family history that could account for the splenic rupture. The patient was taken to the theatre by the surgical team as he remained unstable. He received four units of blood in the theatre and underwent splenectomy due to the spleen being unsalvageable. Post-operatively, the patient was admitted to the high-dependency unit (HDU) for close monitoring. Histological examination of the splenic tissue revealed B-cell lymphoid hyperplasia and negative PCR for clonality. The patient was found to be IgG-positive for mumps and was not vaccinated for MMR. Surgeons believe it is the main cause of ASR, given that little literature available establishes the same. The case highlights the importance of consideration of ASR in patients presenting with unexplained abdominal pain and hemodynamic instability, even without evidence of trauma. Early imaging and operative intervention are lifesaving. The histologic findings indicate that there may be an associated hemopoietic disorder, and this case highlights the need for clinicians to consider splenic involvement in patients with mumps who present with abdominal pain or signs of hemodynamic instability.

Spontaneous rupture of a normal spleen: A case report and a review of the literature emphasizing diagnostic and surgical challenges

INTRODUCTION

Spontaneous splenic rupture (SSR) is a rare but potentially fatal condition. It is commonly linked to underlying conditions such as infections, neoplasms, or hematologic diseases. SSR can also occur in a healthy spleen without any associated pathology, termed idiopathic splenic rupture. Symptoms range from non-specific abdominal pain to hemodynamic instability, often requiring emergency splenectomy. Early recognition using CT is crucial for improving outcomes.

CASE PRESENTATION

A 32-year-old male presented with severe abdominal pain for 24 h. Examination showed stable hemodynamics but tenderness in the left upper quadrant. CT revealed a subcapsular hematoma and moderate hemoperitoneum, leading to a diagnosis of SSR. Initially managed conservatively, the patient developed hemorrhagic shock 24 h later, with hemoglobin decreasing to 6.2 g/dL. An exploratory laparotomy confirmed a superior pole splenic fracture with significant hemoperitoneum, necessitating a total splenectomy. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 6 with prophylactic vaccinations and lifelong penicillin.

DISCUSSION

SSR in a normal spleen is extremely rare and poses significant diagnostic and therapeutic challenges. The exact mechanisms are unclear, with theories including vascular anomalies, microtrauma, increased splenic pressure, and idiopathic factors. SSR symptoms are often non-specific, leading to misdiagnosis. Timely diagnosis using imaging, particularly contrast-enhanced CT, is essential. Management varies from conservative approaches to splenectomy, based on hemodynamic stability and splenic damage.

CONCLUSION

Spontaneous rupture of a normal spleen is a critical condition requiring high clinical suspicion for timely diagnosis and management. Further research is needed to understand its pathophysiology and risk factors.

A rare case of spontaneous hemoperitoneum in a bone marrow transplant recipient on VV-ECMO

A 53-year-old man with acute myeloid leukemia received an allogeneic hematopoietic cell transplant (HCT) from a matched unrelated donor. One month after his transplantation, he developed ARDS requiring initiation of VV-ECMO. He suffered from pancytopenia, managed with frequent transfusions, granulocyte-colony stimulating factor (G-CSF) and weekly thrombopoietin receptor agonist. On ECMO day 17, the patient developed severe hypotension after insertion of a chest tube for a large right-sided pneumothorax. CT angiography of the abdomen showed hemoperitoneum. Exploratory laparotomy revealed approximately 4 L of blood and a ruptured splenic hilum. A splenectomy was performed. Unfortunately, the patient continued to require multiple daily blood products and his condition continued to decline despite two reoperations. His family chose to discontinue ECMO and he passed away peacefully. Spontaneous splenic rupture after GM-CSF has never been reported in patients on VV-ECMO. This manuscript reviews the literature regarding the pathophysiology and clinical manifestation of this rare occurrence.

A Case of Spontaneous Splenic Rupture After a Hemicolectomy on Anticoagulation

Spontaneous or atraumatic splenic rupture (ASR) is a rare but life-threatening condition that requires swift recognition and intervention. We report the case of a 66-year-old female with a history of hypothyroidism, appendiceal goblet cell adenocarcinoma, and new-onset atrial fibrillation (Afib) requiring anticoagulation. She initially presented with right upper quadrant abdominal pain. She had previously undergone an appendectomy followed by a right hemicolectomy to achieve clear surgical margins after the appendiceal carcinoma diagnosis. In the post-anesthesia care unit, she developed Afib and was started on therapeutic anticoagulation. Cardiac catheterization later revealed three-vessel coronary artery disease, prompting a transition from heparin to apixaban. Three days later, the patient suddenly experienced left shoulder pain and was found to be diaphoretic and hypotensive. Three days post-catheterization, the patient developed sudden left shoulder pain, along with diaphoresis and hypotension. An initial concern for post-catheterization myocardial infarction was ruled out. A subsequent CT of the abdomen and pelvis revealed a large splenic hematoma with rupture and hemoperitoneum, necessitating emergent open splenectomy. Post-operatively, the patient required intensive care monitoring and transfusion support before being discharged to a long-term acute care facility. ASR is typically associated with identifiable pathological conditions; however, this case highlights the complexity of multifactorial etiologies. It emphasizes the need to consider ASR in patients presenting with sudden left shoulder pain and hemodynamic instability, particularly when anticoagulation therapy or recent abdominal surgery are factors. This case underscores the importance of a high index of suspicion and timely intervention to prevent fatal outcomes. Further research is warranted to explore the relationship between anticoagulation therapy and ASR.

Atraumatic splenic rupture - unexpected consequences of a world trip

Diagnostic routine and knowledge about the therapy regimes of infectious diseases like malaria gain in importance due to globalization, global warming, and increasing numbers of refugees. We report a case of a 66-year-old patient who presented with severe abdominal pain, most prominent in the left upper abdomen. He was recently hospitalized with severe falciparum malaria, diagnosed after returning from a trip around the world. Upon readmission, laboratory results showed post-artesunate delayed hemolysis. The ultrasound examination was highly suspicious of splenic rupture, confirmed by the immediately performed CT scan. In this case, the prompt diagnosis allowed the initiation of adequate conservative therapy including intensive care monitoring and hemodynamic stabilization.

A Real Gut Punch: An Unexpected Diagnosis of Spontaneous Splenic Rupture

Atraumatic or spontaneous splenic rupture is a rare but life-threatening complication of infectious mononucleosis. We present a case of a 26-year-old man presenting with a 1-week history of sharp epigastric and right upper quadrant pain, associated with malaise and subjective fever. Although initial findings were concerning for acute cholangitis, abdominal computed tomography angiography scan revealed splenic rupture. Further exploration confirmed acute Epstein-Barr virus infection. Infectious mononucleosis must be considered in young patients with lymphocytosis, splenomegaly, and prolonged malaise. Awareness of this presentation will allow for timely diagnosis and treatment, thereby preventing potentially fatal complications of infectious mononucleosis such as splenic rupture.

Atraumatic splenic rupture as first presentation of hairy cell leukaemia-a case report

Atraumatic splenic rupture is a complex surgical pathology owing to its rarity, non-specificity of symptoms and gravity of possible outcomes. This case outlines the investigation and management of a patient with atraumatic splenic rupture secondary to undiagnosed hairy cell leukaemia. While the patient was initially managed conservatively, they went on to have a splenectomy owing to ongoing transfusion requirements. A review of the literature has also been performed and presented to highlight the potential causes of atraumatic splenic rupture and the various options for confirming diagnosis and definitive management.

Atraumatic splenic rupture after administering aspirin, clopidogrel, and heparin to a patient with unstable angina: A case report

It is a rare clinical phenomenon when a normal spleen ruptures spontaneously without any prior trauma. We present a 49-year-old male patient who was discovered to have a splenic rupture after he was referred to our facility as a case of unstable angina for cardiac catheterization based on nonspecific electrocardiogram (ECG) abnormalities and symptoms of chest discomfort coupled with abdominal pain and shortness of breath. He received aspirin, clopidogrel, and heparin before arriving at our emergency department. A splenectomy was performed for the patient, and he recovered well. Despite the rarity of spontaneous splenic rupture, physicians must consider it while evaluating elderly patients who are experiencing abdominal pain while on anticoagulants. Splenic rupture should always be considered, and early diagnosis is essential for a better outcome.

Splenic Arterial Embolization for Trauma and Beyond: A Case Series

Splenic artery embolization plays an important role in the management of various medical and surgical conditions that are non-traumatic in etiology, in addition to its well-established and widely discussed role in managing splenic trauma. In nontraumatic emergencies of catastrophic bleeding originating from the spleen or splenic artery, splenic artery embolization can be effective in achieving hemostasis as a definitive management, temporary stabilizing measure, or preoperative optimization technique. In addition to emergency clinical conditions, splenic artery embolization can be performed electively as an alternative to splenectomy for managing patients with hypersplenism. Herein, we report 6 cases of splenic artery embolization performed at our center to highlight its various indications. This article aims to demonstrate the role of splenic artery embolization in different clinical scenarios and the considerations behind the techniques employed through illustrative cases.

Atraumatic splenic rupture secondary to granulocyte-colony stimulating factor medication exposure

Hematopoietic hormones such as granulocyte-colony stimulating factors are commonly used prevent neutropenia in patients undergoing chemotherapy and to prepare patients for bone marrow donations. In rare cases, splenic injury can result from exposure to this medication. We present the case of a 30-year-old man who presented to the emergency department the day after a bone marrow donation procedure complaining of severe, acute onset left upper quadrant abdominal pain, radiating to the shoulder. Neither the patient nor his family reported any abdominal trauma prior to or following the marrow donation procedure. An initial bedside ultrasound examination was positive for peritoneal fluid and distortion of the normal splenic architecture, raising suspicion for possible intraabdominal or splenic injury. An emergent confirmatory CT with contrast of the abdomen confirmed the initial ultrasound examination suspicion of an atraumatic splenic rupture and with evidence of venous bleeding but without active arterial extravasation. An emergent trauma surgery consultation was placed, and he underwent embolization with an uneventful recovery. This case report highlights the need for a high index of suspicion for atraumatic splenic rupture in patients exposed to these types of granulocyte-colony stimulating factors.

Splenic rupture after surgical fixation of rib fractures with video-assisted thoracoscopic surgery: A case report

INTRODUCTION

Recently, the utilization of surgical stabilization of rib fractures (SSRF) with video-assisted thoracoscopic surgery (VATS) has been increasing owing to its effectiveness. The present report describes the case of a patient who underwent SSRF with VATS and subsequently developed a splenic rupture that was speculated to be related to intrathoracic manipulation during surgery.

PRESENTATION OF CASE

A 62-year-old male patient sustained injuries from a fallen festival car over his thoracoabdominal zone and was diagnosed with bilateral multiple rib fractures and burst fractures of the twelfth thoracic and first lumbar vertebrae. The patient underwent SSRF with VATS. Following surgery, the patient went into hemorrhagic shock due to a splenic rupture, necessitating an emergency open splenectomy.

DISCUSSION

Despite no initial detection of splenic injury on contrast-enhanced CT, it is possible that a slight splenic injury existed at the time of the initial diagnosis. Moreover, during surgery, additional external forces may have been applied to the spleen due to positional changes, such as shifting to the lateral position or retracting the diaphragm using forceps; these manipulations could have potentially caused a slight splenic injury, possibly leading to splenic rupture.

CONCLUSION

When performing SSRF through VATS, it is important to recognize that manipulation and traction of the diaphragm could potentially cause splenic rupture, even if a slight force is applied. Therefore, the diaphragm should be evaluated without traction and manipulation whenever possible.

Spontaneous rupture of splenic hilar lymph node metastasis from hepatocellular carcinoma

Spontaneous rupture of a primary hepatocellular carcinoma (HCC) is a frequently observed and fatal complication. However, the rupture of lymph node (LN) metastases from HCC is rare. A 79 year-old male with hepatitis B underwent three liver resections for HCC. Two years and 6 months after the last liver resection, enhanced computed tomography (CT) revealed a nodule with a diameter of 3 cm in the lower pole of the spleen. Splenic metastasis of HCC was suspected, and splenectomy was scheduled. During our hospital stay for a urinary tract infection before the scheduled operation, he complained of acute left-sided abdominal pain, and CT showed intra-abdominal hemorrhage due to rupture of the splenic tumor. Emergency splenectomy was performed, and the postoperative course was uneventful. Histopathological examination revealed a poorly differentiated HCC in the lower splenic pole lesion, which contained LN structures. The ruptured lesion was diagnosed as splenic hilar LN metastasis of HCC. Although laparoscopic partial liver resection was performed for intrahepatic recurrence, and atezolizumab plus bevacizumab therapy was administered for peritoneal metastases, the patient was alive 25 months after the splenectomy. Our case suggests that emergency surgery for LN metastatic rupture can achieve hemostasis and lead to improved survival outcomes.

Spontaneous Splenic Rupture in a Young Patient: A Comprehensive Case Report and Literature Review

Spontaneous splenic rupture (SSR), a rare but potentially life-threatening condition, typically occurs in the absence of trauma or underlying splenic disease. This report aims to contribute to the limited body of knowledge regarding its occurrence, diagnosis, and management in this demographic. We describe the case of a 20-year-old patient with no significant medical history who presented with acute abdominal pain and hypovolemic shock. Imaging revealed an unexpected splenic rupture without any preceding trauma or identifiable risk factors. The patient's clinical progression, diagnostic challenges, and therapeutic approach are discussed in detail. This case underscores the importance of considering SSR in the differential diagnosis of acute abdomen in young patients, even in the absence of predisposing factors. We review the literature to highlight the epidemiology, possible etiologies, diagnostic modalities, and treatment options for SSR. The peculiarities of managing such cases in young patients are also discussed, emphasizing a tailored approach to balance the risks of conservative management against surgical intervention. In conclusion, SSR, though rare in young patients, should be a diagnostic consideration in cases of unexplained acute abdomen. Early recognition and appropriate management are crucial for favorable outcomes. This case adds to the existing literature by providing insight into the presentation and management of this condition in a young, healthy individual, thereby aiding in enhancing clinical vigilance and patient care.

A case report of successful splenic artery embolization for atraumatic splenic rupture secondary to Epstein Barr virus infection in a haemodynamically unstable patient

Splenic rupture in haemodynamically unstable patients has traditionally been managed with splenectomy. This case report discusses the successful management of atraumatic splenic rupture, a rare but life-threatening complication of Epstein-Barr virus (EBV) infection, in a hemodynamically unstable patient. The patient, diagnosed with infectious mononucleosis (IM) secondary to EBV, presented with severe abdominal pain and a syncopal episode. Imaging revealed an American Association for the Surgery of Trauma (AAST) grade III splenic injury, which was subsequently upgraded to a grade IV injury on repeat imaging. The patient's condition deteriorated even with initial resuscitation, leading to splenic angioembolization. The procedure was successful and the patient was discharged after 5 days. This case highlights the efficacy of splenic artery embolization (SAE) in haemodynamically unstable patients with atraumatic splenic rupture, particularly in centers with interventional radiology resources, offering an alternative to splenectomy and its associated complications.

A rare presentation of spontaneous splenic rupture from plasma cell leukaemia-a case report

Spontaneous/atraumatic splenic rupture is rare, and often associated with underlying infectious disease, or haematological malignancy. Plasma cell leukaemia (PCL) is a rare and aggressive subtype of multiple myeloma, with a higher prevalence of hepatosplenomegaly with a bleeding diathesis from secondary to thrombocytopaenia. We report the case of an 82-year-old male presenting to the emergency department with altered mentation and complaints of left abdominal pain. He presented with haemorrhagic shock. Imaging revealed a spontaneous splenic rupture. He underwent emergency laparotomy and splenectomy for which the histopathology yielded a diagnosis of PCL as the cause for rupture. He received four courses of bortezomib and hyperCVAD 1A therapy. After a long 64-day admission, he recovered well and was discharged home with outpatient haematology/oncology follow-up.

Spontaneous splenic rupture and a congenital splenorenal anomalous shunt

ABSTRACT

Atraumatic splenic rupture is rare and not often considered in the differential diagnosis for patients with abdominal pain. This article describes a patient with atraumatic splenic rupture complicated by a congenital splenorenal anomalous shunt. The congenital anomaly increases patient risk and the degree of surgical difficulty, even if it is identified preoperatively.

Imaging of abdominopelvic oncologic emergencies

With advancements in cancer treatment, the survival rates for many malignancies have increased. However, both the primary tumors and the treatments themselves can give rise to various complications. Acute symptoms in oncology patients require prompt attention. Abdominopelvic oncologic emergencies can be classified into four distinct categories: vascular, bowel, hepatopancreatobiliary, and bone-related complications. Radiologists need to be familiar with these complications to ensure timely diagnosis, which ultimately enhances patient outcomes.

Spontaneous splenic rupture associated with scrub typhus: a case report

BACKGROUND

Scrub typhus, an acute febrile disease with mild to severe, life-threatening manifestations, potentially presents with a variety of complications, including pneumonia, acute respiratory distress syndrome, cardiac arrhythmias (such as atrial fibrillation), myocarditis, shock, peptic ulcer, gastrointestinal bleeding, meningitis, encephalitis, and renal failure. Of the various complications associated with scrub typhus, splenic rupture has rarely been reported, and its mechanisms are unknown. This study reports a case of scrub typhus-related spontaneous splenic rupture and identifies possible mechanisms through the gross and histopathologic findings.

CASE PRESENTATION

A 78-year-old man presented to our emergency room with a 5-day history of fever and skin rash. On physical examination, eschar was observed on the left upper abdominal quadrant. The abdomen was not tender, and there was no history of trauma. The Orientia tsutsugamushi antibody titer using the indirect immunofluorescent antibody test was 1:640. On Day 6 of hospitalization, he complained of sudden-onset left upper abdominal quadrant pain and showed mental changes. His vital signs were a blood pressure of 70/40 mmHg, a heart rate pf 140 beats per min, and a respiratory rate of 20 breaths per min, with a temperature of 36.8 °C. There were no signs of gastrointestinal bleeding, such as hematemesis, melena, or hematochezia. Grey Turner's sign was suspected during an abdominal examination. Portable ultrasonography showed retroperitoneal bleeding, so an emergency exploratory laparotomy was performed, leading to a diagnosis of hemoperitoneum due to splenic rupture and a splenectomy. The patient had been taking oral doxycycline (100 mg twice daily) for 6 days; after surgery, this was discontinued, and intravenous azithromycin (500 mg daily) was administered. No arrhythmia associated with azithromycin was observed. However, renal failure with hemodialysis, persistent hyperbilirubinemia, and multiorgan failure occurred. The patient did not recover and died on the fifty-sixth day of hospitalization.

CONCLUSIONS

Clinicians should consider the possibility of splenic rupture in patients with scrub typhus who display sudden-onset abdominal pain and unstable vital signs. In addition, splenic capsular rupture and extra-capsular hemorrhage are thought to be caused by splenomegaly and capsular distention resulting from red blood cell congestion in the red pulp destroying the splenic sinus.

B-cell hepatosplenic lymphoma presenting in adult patient after spontaneous splenic rupture followed by severe persistent hypoglycaemia: type B lactic acidosis and acute liver failure

A patient was admitted to hospital with splenic rupture, four 4 days after colonoscopy was performed following one month's intermittent and aggravating abdominal pain. During recovery from splenectomy, the patient developed sudden tachycardic and tachypnoea. A blood sample revealed a very low blood glucose, high lactate and acidaemia.The patient required high-dose continuous intravenous glucose, while the lactate remained elevated. Decreasing consciousness with signs of acute liver failure necessitated transfer to an advanced intensive care unit. The patient's clinical status rapidly deteriorated despite therapeutic intervention. The patient died of multiorgan failure eleven days post-splenectomy. Based on the pathology of the spleen and a post-mortem liver specimen, the patient was diagnosed with a primary extra-nodal B-cell hepatosplenic lymphoma (BCHSL) - an extremely rare form of non-Hodgkin lymphomanon.Splenic rupture followed by lactic acidosis and hypoglycaemia should lead to suspicion of a cancer-mediated Warburg effect, and prompt urgent chemotherapy.

Atraumatic splenic rupture associated with COVID-19

Atraumatic splenic rupture (ASR) is a rare but life-threatening condition. Several underlying pathologies have been associated with a splenic rupture in the absence of trauma, most often malignant-haematological disorders, viral infections or local inflammatory disorders. The management of ASR is similar to traumatic splenic rupture and includes early risk stratification of patients to determine those eligible for non-operative treatment versus those who need immediate surgical intervention. In this report, we discuss a rare case of a non-operatively managed ASR in an otherwise healthy young patient with SARS-CoV-2 as the likely aetiology. The multisystemic nature of the ongoing novel COVID-19 is evident, but not all manifestations are yet known. This case report underlines the challenge for physicians in terms of recognising and treating emergent complications of this new disease.

Atraumatic Spontaneous Splenic Rupture With Unknown Etiology

Splenic rupture of all causes is a potentially life-threatening event for patients. The infrequency of atraumatic splenic rupture (ASR) poses a significant diagnostic challenge due to atypical findings. ASR is commonly due to a spleen with an underlying disease process such as malignancy, infection, coagulopathies, or neoplasms. However, ASR without an identifiable cause is rare and poses further complexity. In this case, a 57-year-old woman with a history of hypertension presented to the emergency department complaining of chest pain and was found to have a splenic hematoma. She underwent splenic artery embolization due to her continued hemodynamic instability. The patient was ultimately treated with a splenectomy, as embolization was unsuccessful. Gross pathology revealed no underlying disease processes, nodules, or masses. Splenic hemorrhage due to atraumatic rupture of the spleen is rare and without known pathology. The case illustrates the need for providers to have high clinical suspicion of such a diagnosis to stabilize and surgically manage these patients. Few instances of ASR without an identifiable cause are found in medical literature, and further knowledge of the subject is needed.

Impending splenic rupture as indicator of atypical chronic lymphocytic leukemia: A case report from Saudi Arabia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is one of the hematological malignancies in which the bone marrow overproduces mature, dysfunctional lymphocytes. Affected lymphocytic cells can affect the lymph nodes, spleen, liver, bone marrow, and rarely other organs. Spontaneous rupture of the spleen is a rare health condition, with a few cases caused by CLL. Since the preliminary presentation of either impending or real splenic rupture is unusual and requires recording and reporting, this case report was developed.

CASE REPORT

A 55-year-old male patient presented with a significant weight loss of 20 kg, loss of appetite, fatigue, abdominal pain, and early satiety. Clinical examination revealed massive splenomegaly 22 cm below the costal margin, otherwise unremarkable on systemic examination. The size and dimensions of the spleen were confirmed by computed tomography of the body. The patient underwent a bone marrow biopsy, which was suggestive of atypical CLL. Due to the rapid progression of the size of the spleen and the pattern of impending rupture of the spleen, an emergency splenectomy was performed, and the histopathological report confirmed low-grade B-cell non-Hodgkin's lymphoma, mostly typical of CLL.

CONCLUSION

Given the rarity of cases, continuous data recording and reporting is required to enrich the scientific literature and share experiences from case to case. This will create a complete picture of this health condition across diverse regions and countries.

Atraumatic Splenic Rupture in Legionella pneumophila Pneumonia

A previously fit 46-year-old male handyman presented to a rural hospital with a cough, fever, and epigastric pain without peritonism. The patient was admitted medically with symptoms and radiological appearances consistent with atypical community-acquired pneumonia. During the first 48 hours of admission, he suffered a significant haemodynamic deterioration and was transferred to the intensive care unit (ICU) for vasoactive support. Following stabilisation, urgent abdominal CT imaging demonstrated splenic rupture with haematoma in the absence of historical trauma. Emergency splenectomy was performed; the histopathological examination was unremarkable. Investigations for the presenting complaint confirmed Legionella pneumophila serotype 1 pneumonia by urinary antigen testing. The patient was extubated on postoperative day 2 and stepped down from ICU to complete a 14-day course of azithromycin. Atraumatic splenic rupture is a rarely described clinical entity. The process can be subdivided into pathological and nonpathological (spontaneous) cases. Pathological atraumatic splenic rupture may occur in the context of wide-ranging aetiologies, including bacterial pneumonia; however, the association with Legionella pneumophila serotype 1 is exceptional, with this representing the eighth case in the medical literature.

Spontaneous splenic rupture due to falciparum malaria successfully treated with a conservative approach

Malaria is frequently associated with splenomegaly. However, spontaneous splenic rupture is a rare and life-threatening complication. It is mostly seen in acute infection in non-immune adults and Plasmodium vivax and Plasmodium falciparum have been associated with the majority of cases. We describe a case of splenic rupture in an adult with complicated malaria by Plasmodium falciparum in which a conservative approach was used.

Spontaneous Resolution of Recurrent Pleural Effusion in Atraumatic Splenic Rupture

Spontaneous splenic rupture is an uncommon cause of acute-onset left-sided pleural effusion. It is often immediate with a high preponderance for recurrence, sometimes even requiring splenectomy. We report a case of spontaneous resolution of recurrent pleural effusion presenting a month after the initial atraumatic splenic rupture. Our patient was a 25-year-old male without significant medical history who was taking Emtricitabine/Tenofovir for pre-exposure prophylaxis. He presented to the pulmonology clinic for left-sided pleural effusion, diagnosed in the emergency department a day prior. He had a history of spontaneous grade III splenic injury one month before, where he was diagnosed with cytomegalovirus (CMV) and Epstein-Barr virus (EBV) co-infection on polymerase chain reaction (PCR) testing and was managed conservatively. The patient underwent thoracentesis in the clinic, which showed exudative lymphocyte predominant pleural effusion and no malignant cells. The remainder of the infective workup was negative. He was readmitted two days later with worsening chest pain, and imaging revealed re-accumulation of pleural fluid. The patient declined thoracentesis, and a chest X-ray was repeated a week later, showing worsening pleural effusion. The patient insisted on continuing conservative management, and he was seen a week later with a repeat chest X-ray that showed near resolution of pleural effusion. Splenomegaly and splenic rupture can lead to pleural effusion due to posterior lymphatic obstruction, which can be recurrent. There are no current guidelines on management, and treatment options include watchful monitoring, splenectomy, or partial splenic embolization.

Splenic rupture or infarction associated with Epstein-Barr virus infectious mononucleosis: a systematic literature review

BACKGROUND

Epstein-Barr virus (EBV), also known as human herpesvirus 4, is one of the most common pathogenic viruses in humans. EBV mononucleosis always involves the spleen and as such it predisposes to splenic rupture, often without a trauma, and splenic infarction. Nowadays the goal of management is to preserve the spleen, thereby eliminating the risk of post-splenectomy infections.

METHODS

To characterise these complications and their management, we performed a systematic review (PROSPERO CRD42022370268) following PRISMA guidelines in three databases: Excerpta Medica, the United States National Library of Medicine, and Web of Science. Articles listed in Google Scholar were also considered. Eligible articles were those describing splenic rupture or infarction in subjects with Epstein-Barr virus mononucleosis.

RESULTS

In the literature, we found 171 articles published since 1970, documenting 186 cases with splenic rupture and 29 with infarction. Both conditions predominantly occurred in males, 60% and 70% respectively. Splenic rupture was preceded by a trauma in 17 (9.1%) cases. Approximately 80% (n = 139) of cases occurred within three weeks of the onset of mononucleosis symptoms. A correlation was found between the World Society of Emergency Surgery splenic rupture score, which was retrospectively calculated, and surgical management: splenectomy in 84% (n = 44) of cases with a severe score and in 58% (n = 70) of cases with a moderate or minor score (p = 0.001). The mortality rate of splenic rupture was 4.8% (n = 9). In splenic infarction, an underlying haematological condition was observed in 21% (n = 6) of cases. The treatment of splenic infarction was always conservative without any fatal outcomes.

CONCLUSIONS

Similarly to traumatic splenic rupture, splenic preservation is increasingly common in the management of mononucleosis-associated cases as well. This complication is still occasionally fatal. Splenic infarction often occurs in subjects with a pre-existing haematological condition.

Atraumatic Splenic Rupture: A Notable Complication of Rivaroxaban Use

Direct oral anticoagulants (DOACs) are well known to be associated with bleeding complications. However, little is known about their association with atraumatic splenic rupture, a potentially fatal condition. We present the case of a 73-year-old female with paroxysmal atrial fibrillation managed with rivaroxaban who developed a spontaneous atraumatic splenic rupture. This highlights the importance of recognizing this complication in patients without previous risk factors, such as abdominal trauma or infiltrative splenic disease, who are under anticoagulation with DOACs. There is a strong need for further research on this complication's underlying mechanism and management.

Non-Small Cell Lung Cancer Causing Atraumatic Splenic Rupture Without Splenic Metastasis

Atraumatic splenic rupture (ASR) is a rare occurrence but an important clinical entity. Although trauma is the most common cause of splenic rupture, there is limited literature on ASR. This case report discusses a 59-year-old woman presenting with tension hydrothorax and ASR in the setting of non-small cell lung carcinoma requiring emergent chest tube insertion and emergent splenectomy. Her hospital course was complicated by pulmonary embolism and thrombosis of the inferior vena cava. The patient expired three months after her initial presentation. This patient's presentation represents only the second documented case of atraumatic splenic rupture secondary to metastatic lung carcinoma without pathological evidence of splenic metastasis. Atraumatic splenic rupture secondary to metastatic NSCLC is a rare occurrence; though failure to detect, it may be fatal. Pathologic ASR may be an occult presentation of lung malignancy and in the presence of confirmed NSCLC may portend a poor prognosis.

Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice

BACKGROUND

The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain.

CASE DESCRIPTION

This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living.

DISCUSSION AND CONCLUSION

The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.

Atraumatic splenic rupture in COVID-19 era: case report and systematic literature review

Atraumatic splenic rupture is a rare but life-threatening condition. The Coronavirus disease 2019 (COVID-19) is still a mysterious infection, often associated with spontaneous bleeding and coagulation disorders. Among them, a rare presentation is the atraumatic splenic rupture during SARS-CoV-2 infection. We reported the case of a COVID-19 patient that underwent splenectomy for a spontaneous splenic rupture without splenomegaly or any hematological disorders. Moreover, we reviewed the literature about this matter focusing on the hypothetical etiopathogenesis of this condition in COVID-19 patients. Twelve cases of atraumatic splenic rupture without splenomegaly were reported in ten papers. Coughing, respiratory tract infections and anticoagulant treatment were postulated as the main risk factors for the spontaneous splenic rupture. COVID-19 is still a not well-known disease with multiple clinical presentations. The spontaneous splenic rupture is uncommon in general population but this event should not be neglected in this particular subset of patients.

Atraumatic splenic rupture in a patient treated with rivaroxaban: A case report and a narrative review

Atraumatic splenic rupture (ASR) is a rare condition mostly associated with neoplastic, infectious, and inflammatory diseases. ASR associated with drug treatment is even rarer. In this case report, we highlight an unusual complication of the direct oral anticoagulant rivaroxaban. A 64-year-old male patient was admitted to the emergency department with complaints of faintness and diffuse abdominal cramps. The patient had no history of recent trauma. Clinical examination revealed hemodynamic instability with a moderate response to filling and mild abdominal discomfort on palpation. His medical history included chronic hypertension, constipation, and recent atrial flutter ablation. The patient was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban. Splenic rupture was diagnosed several hours later on contrast-enhanced abdominal computed tomography scan. Massive blood transfusions and emergency laparotomy for splenectomy were performed. Anatomopathological analysis did not reveal any neoplastic, inflammatory, or infectious causes. The patient was successfully discharged from the intensive care unit 3 days later. Clinicians must consider the possibility of ASR as a complication of rivaroxaban in patients with abdominal tenderness and hemodynamic instability. Unfortunately, clinical presentation is not always typical of a ruptured spleen. Delayed diagnosis can be life threatening or fatal. Splenectomy via laparotomy remains the best therapeutic option in cases of splenic rupture in unstable patients on direct oral anticoagulants.

Delayed splenic rupture after a minor blunt trauma: A case report and literature review

Delayed Splenic Rupture (DSR) is a rare but well-known manifestation of Blunt Splenic Injury (BSI), which most commonly occurs following a car accident, a fall from a great height, or a direct blow to the left thorax or abdomen. If the history of trauma is remote or unknown, the diagnosis can be difficult or missed, and a high index of suspicion is not warranted. Regardless of the time and mechanism of the inciting event, DSR should be considered in the differential diagnosis of an acute surgical abdomen. We present a case of DSR in an 81-year-old woman caused by a remote minor blunt abdominal trauma four weeks prior to her admission to our emergency department for acute abdominal pain and hemorrhagic shock (ATLS CLASS III). Starting with this case report, we conducted a literature review on the subject in order to raise awareness, knowledge, and understanding of DSR among emergency clinicians.

A Rare Case of Brucellosis With Spontaneous Splenic Rupture Presenting as an Acute Abdomen

Brucellosis is a common zoonotic infection worldwide caused by the bacterial species Brucella. It has a wide range of presentations from asymptomatic infection to multisystem involvement. Splenomegaly is seen in around 30-60% of cases, however, atraumatic spontaneous splenic rupture is extremely rare. We present a case of a 45-year-old man who presented with acute left upper quadrant pain and fever of five days duration without a history of antecedent trauma. He was hemodynamically stable with examination revealing left upper quadrant tender palpable mass. Ultrasonography followed by computed tomography revealed subcapsular hematoma with perisplenic and perihepatic free fluid. Viral markers (hepatitis B and C, cytomegalovirus {CMV}, Epstein-Barr virus {EBV}, HIV, and dengue) were negative. The autoimmune profile was negative. Brucella serum agglutination test was positive (1: 640) and blood cultures grew Brucella melitensis. He was managed conservatively for splenic hematoma and received one unit blood transfusion and treatment with combination of antibiotics (rifampicin and doxycycline) for brucella for six weeks. On follow-up, the patient reported no further complications. Spontaneous splenic rupture is a clinical rarity and should be considered in patients presenting with acute abdomen and suspected infective, neoplastic, and inflammatory pathology. Spontaneous splenic rupture in acute brucellosis requires prompt clinical recognition and immediate anti-Brucella therapy to prevent the catastrophic progression.

Refractory splenic bleeding from splenic angiosarcoma: A case report and literature review

Introduction and importance

Atraumatic splenic rupture (ASR) is a rare state that accounts for only <1 % of splenic ruptures. One of the causes of ASR is splenic neoplasm such as angiosarcoma. The treatment strategy for ASR is still unclear given the small number of cases reported in detail.

Case presentation

A 75-year-old woman presenting with abdominal pain with shock was referred to our hospital. Emergency computed tomography revealed splenic rupture, and hemodynamic stabilization was obtained by emergent vascular embolization. Rebleeding occurred 27 days after the initial treatment, and splenectomy was performed. Pathologically, ASR was diagnosed as caused by splenic angiosarcoma.

Clinical discussion

ASR is a very rare disease. The etiology of ASR has been reported as neoplastic, infectious, and so on. The treatment for ASR should be decided considering the etiology of ASR, hemodynamic stability, volume of blood transfusion, patient status, severity of the splenic injury, and volume of intraperitoneal bleeding.

Conclusions

We experienced a very rare case of ASR, in which diagnosis was challenging and the timing of surgery was difficult to determine. When splenic rupture has an atraumatic cause, splenectomy should be considered because of the possibility of malignancy.

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The treatment strategy for traumatic splenic rupture is conservative therapy if possible, but that for atraumatic splenic ruptures has not been elucidated.

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In the case of conservative treatment for atraumatic splenic rupture, pathological examination cannot be performed, which may leave the patient untouched if the disease is malignant and at risk of rebleeding.

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Given the challenging diagnostics of angiosarcoma, splenectomy should be considered early in cases of atraumatic splenic rupture.

Complications of lymphoma in the abdomen and pelvis: clinical and imaging review

Involvement of the abdomen and pelvis is common in lymphoma. Nodal and extranodal abdominal and pelvic lymphoma may present with various complications. Complications are most common in high-grade lymphomas, especially diffuse large B-cell lymphoma. Complications may occur as the initial manifestation of lymphoma, during treatment course, or late following complete disease remission. Most complications are associated with worse prognosis and increased mortality. Imaging is essential in evaluation of disease extent and diagnosis of complications. Therefore, radiologists should be familiar with the clinical context and imaging features of abdominal and pelvic lymphoma complications. We provide a comprehensive, organ system-based approach, and clinical and imaging review of complications of abdominal and pelvic lymphoma along with radiologic images of illustrated cases of the most commonly encountered complications.

Chronic lymphocytic leukemia, a rare cause of spontaneous rupture of the spleen

INTRODUCTION

Spleen Spontaneous Rupture SRS is a rare phenomenon in which the spleen ruptures without associated trauma. This pathology is rarely caused by Chronic Lymphocytic Leukemia.

PRESENTATION OF THE CASE

We present a case of a 59-year-old male patient with chronic Lymphocytic Leukemia, who was admitted with an acute abdomen whose clinical and paraclinical examinations revealed a spleen spontaneous rupture. The treatment consisted of a splenectomy.

DISCUSSION

Spontaneous spleen rupture was first described by Rokitansky in 1861 and mentioned in many cases since, the common causes of non-traumatic Splenic rupture include myeloproliferative diseases, vasculitis, and infections. However, Chronic Lymphocytic Leukemia (CLL) remains an obscure cause of splenic rupture that requires unique attention. The diagnosis of splenic rupture should be considered in all patients with hematologic malignancies presenting with abrupt onset of abdominal pain, hemodynamic instability, or acute anemia. The choice between conservative treatment and splenectomy depends on different variables: the etiology of the SRS, the hemodynamic stability, the amount of packed red blood cells transfused. Thus, an interventional approach can be advocated for a spontaneous splenic rupture over nonoperative management. Splenic embolization can provide patients with the advantages of both operative splenectomy and conservative management. The mortality rate from SRS is 12.2 %. Neoplastic pathologies were most significantly associated with fatal outcomes.

CONCLUSION

The high mortality rate seems to be mainly related to the delayed diagnosis and/or the severity of the underlying pathology. Given its seriousness, it requires a rapid diagnosis and adapted management.

Splenic Artery Embolization and Splenectomy for Spontaneous Rupture of Splenic Hemangioma and Its Imaging Features

Background

Spontaneous splenic rupture (SSR) is a rare, often life-threatening, acute abdominal injury that requires immediate diagnosis and early treatment. SSR is mainly treated surgically or conservatively. A few cases of interventional embolization for SSRs have been reported.

Case Presentation

A 30-year-old male patient complaining mainly of left upper abdominal pain underwent emergency abdominal computed tomography (CT) and showed enlargement of the spleen with a massive mixed-density shadow approximately 10.0 × 8.0 × 12.5 cm in size. The boundary was unclear and showed obvious progressive enhancement. Considering the intrasplenic tumor lesions with rupture and hemorrhage, the possibility of vascular tumors was high, with intraperitoneal blood and fluid accumulation. Digital subtraction angiography of the splenic arteriography and embolization of the ruptured splenic artery branches were performed. Postoperative hemoglobin progressively decreased, inflammatory indicators, such as white blood cell counts, procalcitonin (PCT), and C-reactive protein (CRP) were significantly increased, and 2 days after embolization, the patient developed severe hypoxemia, shock, pulmonary edema, and acute respiratory distress syndrome. CT re-examination 9 days after embolization showed reduced lesion absorption. After stabilization of the condition, splenectomy was performed, and postoperative platelet count increase, anticoagulant improvement, and discharge were observed. Postoperative pathological examination revealed extensive hemorrhage and necrosis, vascular tissue with abnormal hyperplasia in the surrounding area, vascular tissue in the bleeding area and outer wall (elastic fiber staining +), and local myofibroblast hyperplasia. Immunohistochemistry showed actin (SM +) and Ki67 (10% +).

Conclusion

SSR caused by splenic hemangioma is rare, and the choice between surgical treatment or splenic artery embolization remains dependent on the patient's hemodynamic stability and imaging findings.

Splenic rupture following lenograstim in post-autologous stem cell transplantation treated with emergency open splenectomy: a case report and literature review

Granulocyte-colony stimulating factors (G-CSFs) are the cornerstone of peripheral blood stem cell mobilization and apheresis. However, splenic rupture following G-CSF treatment represents a serious and potentially fatal adverse event. Here, we report the case of a patient in their late 50s with severe pancytopenia post-autologous stem cell transplantation reinfusion suffering from splenic rupture after treatment with lenograstim. We also reviewed the literature describing cases of splenic rupture during G-CSF administration.

Atraumatic splenic rupture in a child with COVID 19

Background

The majority of children with COVID-19 have only minor symptoms or none at all. COVID-19, on the other hand, can cause serious illness in some children, necessitating hospitalization, intensive care, and invasive ventilation. Many studies have revealed that SARS-CoV-2 affects not only the respiratory system, but also other vital organs in the body. We report here a child with an atraumatic splenic rupture as the initial and only manifestation of COVID-19.

Case presentation

A 13-year-old boy with clinical signs of acute abdomen, left-sided abdominal pain, and hemodynamic instability was admitted to the PICU in critical condition. His parents denied any trauma had occurred. In addition to imaging tests, a nasopharyngeal swab was taken for COVID-19 testing, which was positive. The thoracic CT scan was normal, whereas the abdominal CT scan revealed hemoperitoneum, splenic rupture, and free fluid in the abdomen.

Conclusions

The spleen is one of the organs targeted by the SARS-CoV-2. Splenic rupture, a potentially fatal and uncommon complication of COVID-19, can be the first and only clinical manifestation of the disease in children. All pediatricians should be aware of the possibility of atraumatic splenic rupture in children with COVID-19.

Atraumatic spontaneous splenic rupture in a female COVID-19 patient

Coronavirus disease (COVID-19), an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has severely ravaged the world since the end of 2019. Although most cases range from mild to severe with primarily respiratory symptoms, there have been some unusual clinical presentations, one of which is described in this case report. A 30 year-old woman with no significant medical history presented to the emergency department (ED) in October 2020 with sudden onset of severe left upper and lower abdominal pain. Her initial triaged blood pressure was 70 mmHg systolic, associated with mild tachycardia. Her beta human chorionic gonadotropin (beta-hCG) was negative, and her initial hemoglobin was 9.3 g/dL. A bedside ultrasound (US) was immediately performed, which showed moderate free fluid in the pelvis as well as in the right and left upper quadrants of the abdomen. She was stabilized with a fluid bolus and later underwent a CT scan of the abdomen and pelvis, which showed an apparent grade III splenic laceration without active extravasation. The patient underwent a successful embolization procedure by interventional radiology (IR) and was discharged from the hospital 2 days later. The initial medical workup included a positive polymerase chain reaction (PCR) COVID-19 test but included no other findings that could serve as a cause for her spleen to spontaneously rupture. The purpose of this case report is to illustrate and make other clinicians aware of unusual potential complications and clinical presentations of COVID-19. The condition of spontaneous splenic rupture (SSR) is an uncommon but an emergent differential diagnosis in an otherwise healthy person with potential drastic outcomes. A careful approach in the management and care of these patients is warranted. This is one of a handful of case reports on SSR secondary to COVID-19 to the best of our knowledge.