SESSION TYPE: Infectious Disease Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: A 38-year man with history of symptomatic bradycardia, requiring permanent pacemaker placement and right leg fracture status-post internal fixation presented with increased right lower extremity edema swelling and raised black lesions on extremities, fever and myalgia of two weeks in duration.
CASE PRESENTATION: He denied any history of trauma. The laboratory investigation revealed hemoglobin of 12 gm/dl. An admission chest x-ray revealed right-sided pleural effusion. On the night of admission, the patient had severe abdominal pain and worsening abdominal distention. His repeat hemoglobin level was 4.9gm/dl, prothrombin time and INR were 15.2 and 1.38, respectively. He was in a shock state and received multiple units of packed red blood cell transfusion, and fresh frozen plasma and vitamin K. A CT scan revealed pulmonary opacities, moderate right-sided pleural effusion and a ruptured spleen with a large hematoma and hemoperitoneum. He developed abdominal compartment syndrome and was subsequently intubated with improvement in hemodynamics and renal function. An urgent transcatheter embolization of the splenic artery was performed. A thoracentesis on the right side was done, which showed lymphocyte-predominant exudative fluid. The serology revealed positive IgM mycoplasma. All other serologies were negative. A transdermal biopsy of the skin lesion demonstrated leukocytoclastic vasculitis. The patient was started on vancomycin, meropenem and azithromycin. The patient was extubated on day 7 and discharged a week later.
DISCUSSION: Atraumatic spleen rupture (ASR) is a rare but often life threatening. Three most common causes of ASR have been reported as malignant hematological disorders (16.4%), viral infectious disorders (14.8%) and local inflammatory and neoplastic disorders (10.9%). Splenomegaly is a common feature found in 55% of patients. The ASR-related mortality rate is reported as 12.2%, with splenomegaly and age greater than 40 being associated with higher mortality rates. Neoplastic disorders were significantly associated with a fatal outcome. M.pneumoniae can rarely cause severe pneumonia and multi organ failure. Leukocytoclastic vasculitis, and splenic rupture are uncommon presentations of M. pneumoniae.
CONCLUSIONS: This case exemplifies the importance of having a high index of suspicion for diagnosis of spontaneous splenic rupture and successful management with splenic artery embolization.
1) Renzulli P, et al. Systematic review of atraumatic splenic rupture. British Journal of Surgery. 2009;96:1114-21,.
2) Wehbe E, et al. Spontaneous splenic rupture precipitated by cough: A case report and a review of literature. Scandanavian Journal of Gastroenterology
3) Orloff, MJ. Peskin, GW. Spontaneous rupture of the normal spleen-a surgical enigma. International Abstracts of Surgery. 1958;106:1-11.
DISCLOSURE: The following authors have nothing to disclose: Karl Ziermann, Girish B Nair, Joseph Mathew, Bohsra Louka
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