Spontaneous splenic rupture presenting as haemoperitoneum: coinfection of Plasmodium vivax and Plasmodium falciparum

Abstract

Non-traumatic splenic rupture has been described in the medical literature as a clinical entity with grave consequences, if diagnosis and subsequent treatment are delayed. Various pathological reasons implicated in non-traumatic spontaneous splenic rupture have been described in literature ranging from infection, malignancy, metabolic disorders as well as haematological malignancies. This case reports a 30-year-old man who presented in the emergency department with complaints of fever and a sudden-onset abdominal pain with no history of trauma. At hospital admission, abdominal tenderness with splenomegaly was present with free fluid in abdomen. Haematological investigations established the coinfection of Plasmodium falciparum and Plasmodium vivax. Radiological investigations revealed splenic laceration with moderate haemoperitoneum. The patient was managed conservatively with strict vital monitoring. Later on, elective splenectomy was performed. The authors report only the second case in literature with coinfection of plasmodium species presenting with haemoperitoneum.

Background

Non-traumatic splenic rupture has been described in the medical literature as a clinical entity with grave consequences, if diagnosis and subsequent treatment is delayed.¹ Various pathological reasons implicated in spontaneous splenic rupture have been described in literature ranging from infection, malignancy, metabolic disorders as well as haematological malignancies. Knoblich et al.² have described the non-traumatic rupture of a pathological spleen from the extremely rare non-traumatic splenic rupture of unknown origin.

Malaria is a major health problem in many parts of the world. Though splenic rupture in malaria is rare, but yet it is an important life-threatening complication specially of Plasmodium vivax.³ Here, we report a patient with combined Plasmodiumfalciparum and P vivax malaria who developed spontaneous splenic rupture and was managed successfully with elective splenectomy.

Case presentation

A 30-year-old man presented to emergency trauma centre with a six day history of intermittent high-grade fever with chills and rigours. For the previous 48 h, the patient had abdominal pain, distension and was unable to pass faeces and flatus. At presentation, pulse rate was 108/min and BP 100/70 mm Hg. Spleen was palpable 4 cm below the left subcostal margin and there was evidence of free fluid in abdomen.

Investigations

On investigation, haemoglobin was 5.2 g% with malarial antigen positive for P vivax and P falciparum. Ultrasonography revealed irregular and heterogeneous predominantly hyperechoic areas with intermingled hypoechoic areas suggestive of contusion or laceration with moderate haemoperitoneum (figure 1). To grade splenic trauma, multislice B64 CT scan showed large amount of collection with haemorrhagic attenuation in subcapsular region of spleen (figure 2).

Figure 1.

Ultrasound-guided abdomen showing splenic laceration/contusion.

Figure 2.

CT scan shows subcapsular haematoma in spleen.

Differential diagnosis

Traumatic splenic rupture.

Treatment

The patient was resuscitated with ringer lactate and two units of packed red blood cells (PRBC) and started on injection artesunate 120 mg and broad spectrum antibiotics. Haemophilus influenza and pneumococcal vaccines were given and elective splenectomy was done and gross examination revealed greyish-brown or dark grey discoloured spleen with capsular tears (figure 3).

Figure 3.

Gross resected spleen.

Outcome and follow-up

Microscopy revealed congestion and dilation of sinusoids, mononuclear infiltration with focal necrosis in capillaries and splenic pulp. Patient has made an uneventful recovery.

Discussion

Traumatic splenic rupture is quite common, while non-traumatic splenic rupture may occur in 0.1–0.5% of patients with no associated trauma.⁴ The first case was reported by Rokitansky⁵ in 1861. Various mechanisms that have been implicated in the process include increased intrasplenic tension caused by cellular hyperplasia and engorgement, compression by the abdominal musculature during physiological activities such as sneezing, coughing and defecation and finally, vascular occlusion caused by reticular endothelial hyperplasia which results in thrombosis and infarction. This leads to interstitial and subcapsular haemorrhage and stripping of the capsule consequently further subcapsular haemorrhage.

Malaria is the most common cause of pathological rupture of spleen in the tropics, and life-threatening complications occur in up to an estimated 2%.³ Most cases of pathological rupture of the spleen in malaria occur during acute infection, generally recognised within 3–4 days of the onset of symptoms, while chronically enlarged spleens are less vulnerable to rupture. Spontaneous splenic rupture is more common with P vivax than P falciparum malaria. Among 24 cases reported after 1960, 15 were due to Pvivax, 5 cases were due to Pfalciparum and 2 cases were due to infection from P malariae. One case was due to coinfection of P vivax and P falciparum (this is the second one of which is reported by the author).

Pathological spontaneous rupture of the spleen is also commonly seen in the haematological malignancies, in which fragmentation and dissolution of the fibrous capsule of the spleen occur by infiltrating atypical lymphocytes, as seen in lymphoma/leukaemia. Spontaneous rupture of the spleen due to known cause is extremely rare.^6–8

The most common symptom of splenic rupture is the left upper quadrant abdominal pain which can become generalised as peritonitis sets in. Pallor, tachycardia, hypotension and oliguria may accompany the abdominal symptoms. Diagnosis is based on clinical symptoms and confirmatory diagnostic tests. CT signs may be useful for predicting rupture, and clearly show the grade of splenic damage severity and intraperitoneal free fluid, but is reserved for stable patients.⁶ The management of spontaneous or pathological splenic haemorrhage has been debated constantly. Aggressive management with early surgical intervention is important.⁹ The survival of patients following splenectomy is probably well correlated with the course of the underlying disease. Of the 24 patients described since 1960 (including described above), 17 patients underwent splenectomy.

The trauma literature is replete with data supporting the role of non-operative management of low-grade splenic injuries in haemodynamically stable patients—the same principle has been applied for the management of spontaneous splenic rupture. With improved surgical techniques and supportive care, keeping in view the preoperative and postoperative risk of splenectomy, there has been an emergence of splenic conservation especially in malaria endemic areas.¹⁰ Splenectomy should therefore be reserved for those patients with severe rupture or those with continued and recurrent bleeding.

Learning points.

• Non-traumatic splenic rupture is a rare clinical entity that needs a high index of suspicion for diagnosis.

• The absence of a history of trauma can make it difficult to reach a diagnosis, which causes delay in treatment.

• Rapid diagnosis, aggressive resuscitation and surgical intervention can lead to a successful outcome in patients with spontaneous splenic rupture.