Conservation of the ruptured spleen in children: an African series

Spontaneous Splenic Rupture as a Complication of Malaria and Incidental Acute Appendicitis: A Case Report

Malaria presents a challenge to healthcare systems globally. It is associated with severe complications, notably splenic rupture. The prognosis of malaria complicated by splenic rupture is poor and sometimes leads to death even with timely intervention. Here, we report the case of a patient who presented with complicated malaria with spontaneous splenic rupture and coincidental acute appendicitis. A 34-year-old man was successfully treated for a grade IV ruptured spleen and acute appendicitis with splenectomy and appendectomy. Postoperative care took place in the intensive care unit and the patient was shifted to the general floor on the fifth day. Upon discharge the next day, he was prescribed amoxicillin twice daily for one year. Malaria can present with life-threatening complications requiring prompt surgical intervention.

Sudden spleen rupture in a Plasmodium vivax-infected patient undergoing malaria treatment

Background

Splenomegaly is one of the most common features of malaria. However, spontaneous splenic rupture, although unusual, represents a severe complication often leading to death. It is mostly seen in acute infection and primary attack, and it is most commonly associated with Plasmodium vivax. Here, a case of spontaneous splenic rupture diagnosed with a portable ultrasound apparatus shortly after starting treatment and with recurrent parasitaemia after splenectomy, is reported.

Case description

In November 2015, a 45-year-old Brazilian man presented to the hospital in Manaus with fever, headache and myalgia. He was diagnosed with P. vivax malaria and, after a normal G6PD test, he started treatment with chloroquine and primaquine and was discharged. Two days later, he went back to the hospital with abdominal pain, dyspnea, dry cough, pallor, oliguria and fever. Using a portable ultrasound, he was diagnosed of rupture of the spleen, which was removed by emergency surgery. After this episode, he suffered two more malaria episodes with high parasitaemia at approximately 2-month intervals. DNA from different portions of the spleen was extracted and a qualitative PCR was performed to detect P. vivax.

Conclusions

The splenic rupture suffered by this patient occurred 2 days after starting the treatment. Having a portable ultrasound apparatus may have saved the patient’s life, as it revealed a haemorrhage needing an urgent surgery. Parasites were detected by PCR in the extracted spleen. This patient suffered two more vivax malaria diagnosed episodes in spite of receiving and completing treatment with chloroquine and primaquine for each clinical attack. Splenic rupture during acute malaria is uncommon, but it is likely underdiagnosed and underreported, because the lack of means and equipment hinders diagnostic confirmation, especially in endemic areas.

Non-operative management of malarial splenic rupture: the Khartoum experience and an international review

Malarial splenic rupture (MSR) occurs in a subset of patients and can be an acute surgical emergency. MSR is a well-known entity for more than 100 years, yet there are no well-structured studies in the literature that systematically evaluate this complication. While it has become increasingly recognized that splenic salvage can be vital to the long term immunity and health of these patients, there are few data to guide a safe approach to non-operative management of these patients. Current knowledge of spontaneous rupture of the spleen has been gained largely though reported cases. We present 2 cases of MSR and a review of the literature of the management of MSR. We present an algorithm for the management of MSR. Of the 60 cases of MSR in the literature 31 were managed with splenectomy, 21 were managed non-operatively, and 8 early deaths occurred during initial presentation. The most common presenting symptoms were fever (67%) and abdominal pain (51%). Seventy-two percent of patients were hypotensive and tachycardic on presentation. Fifteen (71%) of 21 patients had successful non-operative management for MSR. Of the six patients that failed non-operative treatment, 4 patients eventually needed splenectomy, and 2 patients died without operation. We recommend that patients presenting with fever, abdominal pain, hypotension, and spenomegaly receive urgent resuscitation, ultrasonography (where available) to evaluate for blood in the abdomen, and surgical consultation. Patients who are hemodynamically stable before or after resuscitation can be selectively chosen for non-operative management.

Pathological rupture of the spleen in malaria: analysis of 55 cases (1958-2008)

BACKGROUND

Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated.

METHOD

We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages.

RESULTS

Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture.

CONCLUSIONS

Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.

Conservative management of splenic injury in the tropics

We undertook this study in order to determine whether the conservative management of splenic injuries is a safe practice in a low-volume tropical hospital. We evaluated 69 consecutive patients with splenic injury prospectively. The outcome measures were morbidity and mortality rates, overall hospital stay and blood transfusion requirements. Spleen preservation was achieved in 85% (59) of cases. Of the 16 patients who underwent splenic surgery, six had splenorraphy (38%). The overall mortality was 4.3% (3) and the deaths were not related to the conservative management. Our findings suggest that not only is the conservative management of splenic injuries safe, but also that the repair of an enlarged spleen (splenorrhaphy) is safe and feasible in tropical hospital settings. The findings in this study provide further evidence that the conservative management of splenic injury in a tropical hospital without computed tomography scan is a safe practice.