Non-traumatic splenic rupture secondary to haemorrhagic infarct in diffuse large B-cell lymphoma

Description

A 62-year-old man with stage IV follicular lymphoma presented with acute left-sided abdominal pain, acute-on-chronic anaemia and thrombocytopenia. An urgent contrast-enhanced CT scan of the abdomen demonstrated the presence of haemoperitoneum. Irregular linear-branching hypodensities distorting the splenic parenchyma present in both arterial (figure 1) and portovenous phases (figure 2), with presence of ill-defined hypoenhancing regions. Splenomegaly was present. Notably, there was absence of trauma. Overall features were compatible with non-traumatic rupture of the spleen.

Figure 1.

Contrast-enhanced CT scan of the abdomen performed in the arterial phase (A) and portovenous phase (C) demonstrating the presence of haemoperitoenum (red arrows) and persistence of irregular, linear-branching hypodensities (yellow arrows) that traverse across the entire thickness of the enlarged spleen. No active contrast extravasation is seen. In this setting of spontaneous acute abdominal pain without prior abdominal injury, CT features were compatible with non-traumatic rupture of the spleen.

Figure 2.

Contrast-enhanced CT scan of the abdomen performed in the portovenous phase (A,B), demonstrating the diffuse extent of splenic rupture, with involvement of multiple sites (yellow arrows). Haemoperitoneum (red arrows) is once again seen at the perisplenic region.

The patient underwent emergency laparotomy, revealing 3 L of blood clots in the peritoneal cavity. Slow oozing of blood was noted at the region of the splenic hilum. Splenectomy was performed. Histopathological evaluation demonstrated features of diffuse large B-cell lymphoma with subcapsular infarct and haemorrhage. The surgery was uneventful. However, due to concurrent comorbidities and general ill-health, the patient progressively deteriorated and finally succumbed about a month after the surgery.

Non-traumatic splenic rupture is widely regarded as uncommon,¹ but limited case reports advocate the early recognition and intervention of this rare disease entity.² Several authors have also attributed the low index of suspicion as a major reason for the delayed diagnosis of similar cases of spontaneous splenic rupture secondary to non-Hodgkin’s lymphoma.³ A high index of suspicion should hence be raised in selected patient groups such as those with a background of haematological malignancy and splenomegaly who present with acute abdominal pain, to urgently evaluate for this potentially life-threatening disease.

Learning points.

• Non-traumatic splenic rupture should be considered in patients with splenomegaly, particularly those with pre-existing disease such as haematological malignancy.

• Prompt imaging is useful in confirming splenic rupture and can lead to early splenectomy, reducing morbidity and mortality in this potentially life-threatening disease entity.