Large B-cell lymphoma presenting as acute abdominal pain and spontaneous splenic rupture; a case report and review of relevant literature

Delayed Traumatic Rupture of the Spleen in a Patient with Mantle Cell Non-Hodgkin Lymphoma after an In-Hospital Fall: A Fatal Case

Splenic rupture and hematoma are significant complications that can occur in patients with non-Hodgkin lymphoma (NHL). Understanding these associated complications is essential for optimal patient management and enhanced patient outcomes. Histopathological and immunohistochemical analyses are crucial in diagnosing NHL and assessing splenic involvement. In this study, a judicial autopsy had been requested by the Prosecutor's Office for a malpractice claim due to a fall in the hospital. In the Emergency Department, a 72-year-old man fell from a gurney and reported sustaining a wound to his forehead. No other symptoms were reported. A face and brain CT scan showed no abnormalities. Nine days after discharge, the patient presented with abdominal pain. An abdominal CT revealed splenic rupture and hemoperitoneum. The patient underwent open splenectomy but showed signs of hemodynamic shock and subsequently died. The evidence from the autopsy allowed us to diagnose mantle cell non-Hodgkin lymphoma with spleen involvement, previously unknown. Histopathological and immunohistochemical analyses were performed to assess the diagnosis of splenic rupture and estimate its timing. The findings strongly suggest that the splenic rupture was associated with the patient's fall and the pre-existing malignancy. This case highlights the importance of considering an underlying hematological malignancy when investigating delayed splenic rupture. An immunohistochemical study of spleen samples allowed the timing of splenic hematoma and rupture to be assessed, leading to the establishment of a causal relationship with trauma.

An unusual case of a traumatic splenic rupture masquerading as myocardial ischemia: a case report

Background

The spleen is one of the most frequently injured abdominal organs during trauma, which can result in intraperitoneal bleeding of life-threatening magnitude. Although splenic injury secondary to trivial trauma comprises a minor fraction of abdominal injuries, undiagnosed or delayed diagnosis may result in a complicated clinical course.

Case presentation

One such event is presented here, wherein a late diagnosis of an advanced grade splenic injury following a trivial trauma initially presented in disguise as acute myocardial ischaemia in a previously healthy South Asian woman in her late 30s. Emergency laparotomy and splenectomy were performed with simultaneous massive transfusion for a 3.5-L blood loss. She subsequently had an uncomplicated clinical course with regular surgical follow-up.

Conclusion

Splenic injuries might present with ambiguous symptoms such as atypical chest pain and shoulder pain, necessitating attending clinicians to have a high degree of suspicion, especially in busy units such as the emergency department (ED).

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.

Characteristics and surgical outcomes of patients with atraumatic splenic rupture

OBJECTIVE

Although rare, late-diagnosed atraumatic splenic rupture (ASR) may result in mortality. We investigated the occurrence of ASR cases at our centre over the previous six years.

METHODS

This was a retrospective, cross-sectional study that included all patients who underwent emergency splenectomy due to ASR between January 01, 2015, and January 01, 2021.

RESULTS

Of the 203 patients who underwent splenectomy, 15 met our criteria for ASR. Median age was 55 years (34-90), and 10 (67%) patients were male. Most common pre-existing diseases were diabetes mellitus (6, 40%) and heart valve disease (5, 33%). Ten (67%) patients had splenic rupture due to splenic infarction and abscess. There were two (13%) cases with diffuse large B cell lymphoma (DLBCL) and two (13%) cases with lung cancer and spleen metastasis. Median length of hospital stay was 6 days (2-24) and three (20%) patients died in hospital.

CONCLUSIONS

Male sex, previous splenic infarctions, haematological malignancies, lung cancer spleen metastases, underlying cardiovascular disease and diabetes mellitus may increase the risk for ASR. Further prospective controlled studies are needed to confirm our results.

Spontaneous splenic rupture: A rare complication of acute myeloid leukemia. Report of a case

Introduction

Spontaneous rupture of the spleen (SPR) is a rare and severe affection, difficult to diagnose, with multiple causes such as: Infectious and hematologic affections which represent more than half of the cases. Among this subset of patients, acute myeloid leukemia is one of the causes.

Presentation of case

A 48-year-old man undergoing chemotherapy for acute myeloid leukemia presented with acute intense abdominal pain. Computed tomography showed Abdominal CT scan showed a splenic rupture with abundant hemoperitoneum and bilateral pleural effusion. The patient presented hemodynamic instability and was immediately operated, splenectomy were performed.

Discussion

Spontaneous rupture of the spleen usually presents as a severe abdominal syndrome, which may accompany non-specific symptoms.Two signs are suggestive of splenic rupture: Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) and Balance's sign (palpable tender mass in the left upper quadrant. Diagnostic methods of choice are computed tomography andultrasound. The prognosis is depending on the quality of care and the nature of the etiology. Splenectomy remains the cornerstone of the treatment of splenic rupture. It is important to include splenic rupture as a differential diagnosis for acute abdominal pain, especially in patients with hematologic malignancy, since early recognition and treatment increase patient survival and improve the prognosis.

Conclusion

Even if spontaneous splenic rupture is rare, every clinician should have in mind the reflex to think of it, especially in patients with hematologic malignancies.

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The objective of this study is to highlight the seriousness of this condition and the different diagnostic and therapeutic modalities.

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Spontaneous rupture of the spleen (SPR) is a rare and severe affection, difficult to diagnose.

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The prognosis is depending on the quality of care and the nature of the etiology.

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Splenectomy remains the cornerstone of the treatment of splenic rupture.

Spontaneous splenic rupture in a patient with chronic myeloid leukemia: A case report

INTRODUCTION

Spontaneous splenic rupture is an atraumatic event that represents a rare and life-threatening acute complication in which the spleen is damaged producing internal hemorrhage in the abdominal cavity. Its association with hematologic malignancies, although a rare occurrence, has been previously described. Among this subset of patients, chronic myeloid leukemia is one of the main causes.

PRESENTATION OF CASE

A 26-year-old male with history of chronic myeloid leukemia presented with acute intense abdominal right lower quadrant pain. Computed tomography showed a wedge in the lower third of the spleen (probably associated with infarction), active bleeding, and hemoperitoneum. Laparotomy and splenectomy were performed.

DISCUSSION

The most common symptom of spontaneous splenic rupture is acute abdominal pain, sometimes radiating to the left shoulder. It can also be associated with nausea, emesis and signs of hypovolemia or shock. Splenomegaly may be absent. Diagnostic methods of choice are computed tomography and ultrasound. Management of splenic rupture is divided in surgical and conservative. The former is reserved for patients with extensive splenic injury that is accompanied by hemodynamic instability or other trauma that warrants surgical treatment. Patients who do not meet these criteria and respond to initial stabilization strategies can be offered clinical and laboratory monitoring. Stable patients with moderate to severe splenic injuries can be offered angioembolization.

CONCLUSION

It is important to include splenic rupture as a differential diagnosis for acute abdominal pain, especially in patients with hematologic malignancy, since early recognition and treatment increases patient survival and improves prognosis.

Non-traumatic splenic rupture - a rare first presentation of diffuse large B-cell lymphoma and a review of the literature

Background

Cases of non-traumatic splenic rupture are rare and entails a potentially grave medical outcome. Hence, it is important to consider the differential diagnosis of a non-traumatic splenic rupture in patients with acute or insidious abdominal pain. The incidence of rupture in Diffuse B-cell non-Hodgkin Lymphoma is highly infrequent (Paulvannan and Pye, Int J Clin Pract 57:245–6, 2003; Gedik et el., World J Gastroenterol 14:6711–6716, 2008), despite reports of various non-traumatic splenic rupture in the literature (Orloff and Peksin, Int Abstr Surg 106:1-11, 1958; Paulvannan and Pye, Int J Clin Pract 57:245–6, 2003). In this article, we attempt to highlight the features of a rare cause of splenic rupture that might serve as a future reference point for the detection of similar cases during routine clinical practice.

Case presentation

A 40-year-old man presented with 1 week history of left hypochondriac pain associated with abdominal distention. There was no history of preceding trauma or fever. Clinical examination revealed signs of tachycardia, pallor and splenomegaly. He had no evidence of peripheral stigmata of chronic liver disease. In addition, haematological investigation showed anemia with leucocytosis and raised levels of lactate dehydrogenase enzyme. However, peripheral blood film revealed no evidence of any blast or atypical cells. In view of these findings, imaging via ultrasound and computed tomography of the abdomen was performed. The results of these imaging tests showed splenic collections that was suggestive of splenic rupture and hematoma. Patient underwent emergency splenectomy and the histopathological report confirmed the diagnosis as DLBCL.

Conclusions

The occurrence of true spontaneous splenic rupture is uncommon. In a recent systematic review of 613 cases of splenic rupture, only 84 cases were secondary to hematological malignancy. Acute leukemia and non-Hodgkin lymphoma were the most frequent causes of splenic rupture, followed by chronic and acute myelogeneous leukemias. At present, only a few cases of diffuse large B-cell lymphoma (DLBCL) have been reported. The morbidity and mortality rate is greatly increased when there is a delay in the diagnosis and intervention of splenic rupture cases. Hence, there should be an increased awareness amongst both physicians and surgeons that a non-traumatic splenic rupture could be the first clinical presentation of a DLBCL.

Unusual Presentation of Diffuse Large B-Cell Lymphoma With Splenic Infarcts

A 67-year-old man presented with a 3-day history of abdominal pain, fever, and significant weight loss over 2 months. Physical examination revealed left upper quadrant tenderness, hepatomegaly, splenomegaly, and bilateral pitting edema but peripheral lymphadenopathy was absent. Laboratory tests showed anemia, thrombocytopenia, elevated prothrombin time (PT), partial thromboplastin time (PTT), and increased lactate dehydrogenase (LDH). PTT was corrected completely in mixing study. Further workup for the cause of coagulopathy revealed decreased levels of all clotting factors except factor VIII and increase fibrinogen levels, which ruled out disseminated intravascular coagulation (DIC). Flow cytometry of peripheral blood was normal. Contrast-enhanced computed tomography (CECT) revealed splenomegaly with multiple splenic infarcts without any mediastinal or intraabdominal lymphadenopathy. Further investigations for infective endocarditis (blood cultures and transthoracic echocardiography) and autoimmune disorders (ANA, dsDNA, RA factors) were negative. The patient received treatment for sepsis empirically without any significant clinical improvement. The diagnosis remained unclear despite extensive workup and liver biopsy was conducted due to high suspicion of granulomatous diseases. However, the liver biopsy revealed high-grade diffuse large B-cell lymphoma (DLBCL). Unfortunately, patient died shortly after the diagnosis. Here we report a case of high-grade DLBCL with hepatosplenomegaly and splenic infarcts in the absence of any lymphadenopathy or focal lesions. This case highlights the fact that unusually lymphoma can present in the absence of lymphadenopathy or mass lesion mimicking autoimmune and granulomatous disorders. The diagnosis in these cases can only be made on histology, and hence the threshold for biopsy should be low in patients with unclear presentations and multiorgan involvement.

Pathologic Rupture of the Spleen as the Presenting Symptom of Primary Splenic Non-Hodgkin Lymphoma

Pathologic splenic rupture is defined as the spontaneous rupture of a diseased spleen and is quite rare. It is usually associated with oncologic, infectious, and hematologic diseases and more seldom with other rare causes. Pathologic splenic rupture related to hematologic malignancy seems to be rare with only 136 cases reported from 1861 until 1996 and a few cases thereafter. Non-Hodgkin lymphoma and acute myeloid leukemia are most frequently reported followed by chronic myeloid leukemia and lymphoblastic acute leukemia. However, even in cases of non-Hodgkin lymphoma, pathologic splenic rupture as the presenting symptom of the disease is rare as is the presence of primary splenic lymphoma. Conservative treatment is not an option, while operative intervention and emergency splenectomy is the only feasible treatment. We present a very rare case of pathologic rupture of primary splenic lymphoma which was the presenting symptom of the disease.

Splenic marginal cell lymphoma (SMZL): report of its presentation with spontaneous rupture of the spleen

Rupture of the spleen is a potentially life-threatening condition, which most often occurs secondary to abdominal trauma. Spontaneous rupture of the spleen is a much rarer event, usually occurring secondary to infections and less frequently secondary to haematological malignancies causing massive splenomegaly. We present a case of a 71-year-old woman who presented in the emergency department with acute abdominal and back pain and no history of trauma, with a CT scan diagnosis of splenic rupture. Splenectomy was performed and the histological examination of the specimen revealed splenic marginal cell lymphoma (SMZL), which is classified under the non-Hodgkins lymphomas (NHL) and accounts for <1% of NHL. There is only one previously reported case of spontaneous splenic rupture SMZL and this is the first recorded case of spontaneous splenic rupture in a patient without massive splenomegaly.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

BACKGROUND

Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion.

METHODS

Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.

RESULTS

We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy.

CONCLUSIONS

Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

Proximal splenic artery embolization in the management of splenic rupture

OBJECTIVE

To report the use of proximal splenic artery embolization for management of spontaneous splenic rupture.

DESIGN

Case report and literature review.

SETTING

A tertiary pediatric critical care unit in a university teaching hospital.

INTERVENTIONS

Proximal splenic artery embolization.

MEASUREMENTS AND MAIN RESULTS

An 8-yr-old boy presented with abdominal pain radiating to the left shoulder 9 days after completing induction chemotherapy for acute lymphoblastic leukemia. Imaging revealed a splenic rupture with parenchymal and subcapsular hematomas, with no evidence of active extravasations. The patient was admitted to the pediatric critical care unit for close hemodynamic monitoring and frequent measurements of hemoglobin. His lowest recorded hemoglobin and hematocrit were 63 g/L and 0.19 L/L, respectively. Posttransfusion of packed red blood cells, he was taken to interventional radiology for proximal splenic artery embolization under moderate sedation. Several coils were successfully placed in the proximal splenic arterial system resulting in a marked reduction of splenic blood flow without disruption of collaterals. The patient recovered well from proximal splenic artery embolization in the pediatric critical care unit and experienced short lasting abdominal pain and fever for 1 day. He was discharged home 4 days after the procedure and follow-up imaging showed resolving hematomas with preserved splenic blood flow.

CONCLUSION

Proximal splenic artery embolization in children may be a safe therapeutic alternative to either conservative or surgical management in spontaneous splenic rupture. Preservation of splenic tissue with a reduced risk of repeated hemorrhage can be obtained with proximal splenic artery embolization.

Non-traumatic splenic rupture: Report of seven cases and review of the literature

AIM: To evaluate seven patients with non-traumatic splenic rupture (NSR). NSR is an uncommon dramatic abdominal emergency that requires immediate diagnosis and prompt surgical treatment to ensure the patient’s survival.

METHODS: Within 11 years, seven cases were evaluated for patient characteristics, anamnesis and symptoms, method of diagnosis, findings of laparotomy, and etiology of NSR.

RESULTS: There were six (86%) male and one female (14%) patient, whose mean age was 36 ± 12.8 (17-56) years. We report here four cases of Plasmodium vivax malaria (cases I-IV), one case of hemodialysis (case V), one case of spontaneous splenic rupture (case VI), and one case of hairy cell leukemia (case VII). Splenectomy was performed in all patients. All of them made an uneventful recovery and were discharged in stable condition.

CONCLUSION: NSR is a rare entity that needs a high index of suspicion for diagnosis. Using ultrasonography or computer tomography, and peritoneal aspiration of fresh blood may assist in the diagnosis of NSR. Increased awareness of NSR can enhance early diagnosis and effective treatment.