INTRODUCTION: Spontaneous splenic rupture (SSR) is a rare but potentially life threatening condition demanding rapid diagnosis and treatment.
CASE PRESENTATION: 72-year-old Caucasian female with history of chronic obstructive pulmonary disease (COPD), hypertension and hypothyroidism presented to an outside hospital with complaints of shortness of breath and cough. She was treated for COPD exacerbation and community acquired pneumonia with steroids, bronchodilators and antibiotics. During the second day of her hospital stay she complained of chest pain and her electrocardiogram was suggestive of non-ST elevation myocardial infarction. Patient was then transferred to our facility for further management. She was given Lovenox 75 milligrams twice a day as a part of her treatment for ACS. On fourth hospital day she was found to be hypotensive with blood pressure 60/40 millimeters of mercury and was transferred to intensive care unit. Laboratory data revealed white cell count 25,000 per cubic millimeter, hemoglobin 9.8 grams per deciliter (gm/dl), hematocrit 29%, platelet count 170,000 per microliter, lactic acid 7.2 millimoles per liter, PT 18 seconds, INR 1.6, PTT 39 seconds. Differential diagnosis included septic and cardiogenic shock. She was fluid resuscitated, started on vasopressors for cardiovascular support and intubated for increase work of breathing. Six hours later hemoglobin and hematocrit dropped to 5.5 gm/dl and 15.9%. Suspected hemorrhagic shock was treated with packed red blood cells (PRBC) and fresh frozen plasma (FFP) transfusions. Computed Tomography (CT) Abdomen/Pelvis with oral contrast showed bilateral rectus sheath hematomas and large collection of intra-abdominal fluid/blood. Emergent exploratory laparotomy was performed and 4.5 liters of blood was evacuated from the peritoneal cavity. Spleen was found to be ruptured and splenectomy was performed with good control of the hemorrhage. Rectus sheath hematomas were evacuated. Pathologic examination of the spleen revealed a normal size spleen (126gm) with capsular disruption, areas of focal congestion, and no specific pathologic change. Patient's condition improved and she was eventually discharged to a rehabilitation facility.
DISCUSSIONS: Spontaneous splenic rupture unlike traumatic splenic rupture is a rare and thus a less recognized clinical entity. Orloff and Peskin (1) identified four criteria that define spontaneous splenic rupture: no history of trauma, no perisplenic adhesions suggestive of previous trauma, the absence of disease that affects the spleen itself and normal microscopic and macroscopic appearance of spleen. Negative serology for viral antibody titers suggestive of recent infection with types that affect spleen was added as a fifth criterion. Our patient fulfilled first four criteria, however viral serologies were not obtained. Many theories have been postulated to explain SSR that occurs in the absence of disease or trauma. A sudden increase in intra-abdominal pressure associated with exercise, coughing, or vomiting have been implicated as a potential cause of SSR. In our patient the cough was mild and intermittent. Splenic rupture typically manifests as abdominal pain and/or a falling hematocrit or shock. Laparotomy remains the diagnostic gold standard. CT scan is 89 to 96% sensitive and can more precisely localize the bleeding, however, in this case report the CT scan did not show splenic rupture but it did reveal bilateral rectus sheath hematomas and large amount of intra-abdominal fluid/blood. There are separate case reports of either abdominal wall hematoma or spontaneous splenic rupture where low molecular weight heparin (LMWH) was the only identifiable risk factor. In our case report both of these conditions were coexistent and no risk factor other than lovenox therapy could be identified.
CONCLUSION: This case reminds us that high index of suspicion is prudent to recognize spontaneous splenic rupture as a cause of shock in a patient on LMWH therapy.
DISCLOSURE: Soophia Khan, No Financial Disclosure Information; No Product/Research Disclosure Information