Possible Infectious Causes of Spontaneous Splenic Rupture: A Case Report

Grace Y Lam; Adrienne K Chan; Jeff E Powis

Disclosures

J Med Case Reports. 2014;8(396) 

In This Article

Abstract and Introduction

Abstract

Introduction Spontaneous atraumatic splenic rupture is a rare but dramatic occurrence that is most commonly attributed to infection or neoplasia. Deciphering the etiology can be challenging with many cases remaining unclear despite full investigation.

Case presentation We report the case of a previously healthy and immunocompetent 52-year-old Caucasian woman with a remote history of clinically diagnosed infectious mononucleosis who experienced sudden atraumatic splenic rupture after an untreated stray cat bite.

Conclusions The differential diagnosis for atraumatic splenic rupture, specifically its infectious causes, is reviewed. Key clinical and laboratory findings that differentiate Bartonella henselae infection and Epstein–Barr virus reinfection are reviewed.

Introduction

Splenic rupture typically presents nonspecifically with left upper quadrant abdominal tenderness with or without distention, syncope, and a rapid drop in blood pressure. If severe, shock and alterations in level of consciousness may also be observed. Its diagnosis is most often established with ultrasonographic or computed tomography (CT) abdominal imaging. However, determining the etiology is often more difficult. The causes of splenic rupture can be generally divided into two categories – traumatic or atraumatic – where trauma explains the majority of cases. The diagnosis of atraumatic splenic rupture (ASR) can be made with the Orloff and Peskin criteria, which states that ASR can be diagnosed when the following four criteria are met: 1) thorough history reveals no antecedent trauma; 2) no evidence of disease in organs other than the spleen that can cause rupture; 3) no perisplenic adhesions or scarring consistent with trauma or past rupture; and 4) normal spleen on gross and histological examination.[1]

The causes of ASR are varied and can be classified into seven main categories: neoplastic, infectious, hematological, inflammatory, iatrogenic, primary splenic causes or idiopathic (see Table 1).[2] Proportionally, neoplasia and infection account for more than half of the cases.[3]

Regardless of etiology, the immediate management of ASR can be varied, depending on the degree of splenic injury.[4] If the degree of splenic injury is mild, then conservative therapy consisting of fluids, with or without blood transfusion(s) and intensive care unit (ICU) admission for close monitoring may be sufficient.[4] If severe, then splenic artery embolization, splenic salvage, or splenectomy may be indicated when conservative management fails to achieve hemodynamic stabilization.[4] Approximately 20 to 40% of patients require surgical intervention.[5] Finally, patients should be advised to avoid high impact sports post-injury between 1 and 6 months post-rupture, depending on the degree of splenic injury.[6] Evidence for serial CT imaging to document splenic healing prior to resumption of activities is poor and is only recommended in select individuals and activities.[7] In patients post-splenectomy, there is strong evidence to encourage patients to receive pneumococcal vaccination due to reduced immunity towards encapsulated organisms.[8] Vaccination for patients undergoing nonoperative conservative management remains controversial.[9]

In the following case report, we describe an atypical case of ASR secondary to an infectious etiology and the methods used to determine the cause.

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