[The 506th case: fever of unknown origin, negative PET-CT and hemoperitoneum].

A 48-year-old male was admitted to Peking Union Medical College Hospital presented with intermittent fever for two years. The maximum body temperature was 39 ℃, and could spontaneously relieve. The efficacy of antibacterial treatment was poor. He had no other symptoms and positive signs. He had a significant weight loss, and the serum lactate dehydrogenase increased significantly. It was highly alert to be lymphoma, but bone marrow smear and pathology, and PET-CT had not shown obvious abnormalities. Considering high inflammatory indicators, increased ferritin and large spleen, the patient had high inflammatory status, and was treated with methylprednisolone. Then the patient's body temperature was normal, but the platelet decreased to 33×109/L. During hospitalization, he had suddenly hemoperitoneum and hemorrhagic shock. He was found spontaneous spleen rupture without obvious triggers, and underwent emergency splenectomy. The pathological diagnosis of spleen was diffuse large B-cell lymphoma.

Ultraselective angioembolisation of splenic artery for atraumatic spleen rupture in a patient of systemic lupus erythematosus.

A systemic lupus erythematosus (SLE) patient in her mid-30s presented with spontaneous splenic haematoma and rupture. She rapidly deteriorated despite packed red cells and fresh frozen plasma transfusions. She underwent emergent ultraselective angioembolisation of the splenic artery and got stabilised. Spontaneous or atraumatic splenic rupture is rare in SLE and splenic artery embolisation may be life-saving.

Successful management of postpartum venous thrombosis following splenectomy for traumatic splenic rupture: a case report.

Traumatic splenic rupture is rare in pregnant women; and multiple venous thromboses of the portal vein system, inferior vena cava and ovarian vein after caesarean section and splenectomy for splenic rupture has not been previously reported. This case report describes a case of multiple venous thromboses after caesarean section and splenectomy for traumatic splenic rupture in late pregnancy. A 34-year-old G3P1 female presented with abdominal trauma at 33+1 weeks of gestation. After diagnosis of splenic rupture, she underwent an emergency caesarean section and splenectomy. Multiple venous thromboses developed during the recovery period. The patient eventually recovered after anticoagulation therapy with low-molecular-weight heparin and warfarin. These findings suggest that in patients that have had a caesarean section and a splenectomy, which together might further increase the risk of venous thrombosis, any abdominal pain should be thoroughly investigated and thrombosis should be ruled out, including the possibility of multiple venous thromboses. Anticoagulant therapy could be extended after the surgery.

Spontaneous splenic rupture and a congenital splenorenal anomalous shunt.

ABSTRACT: Atraumatic splenic rupture is rare and not often considered in the differential diagnosis for patients with abdominal pain. This article describes a patient with atraumatic splenic rupture complicated by a congenital splenorenal anomalous shunt. The congenital anomaly increases patient risk and the degree of surgical difficulty, even if it is identified preoperatively.

Peliosis of the spleen as an unusual cause of splenic rupture: A case report and a review of literature.

Isolated splenic peliosis is an extremely rare condition characterized by the presence of multiple blood-filled cavities, occasionally resulting in non-traumatic splenic rupture with fatal bleeding. In our case, a 64-year-old man was brought by ambulance due to weakness and abdominal pain without nausea or febrility. On clinical examination, the patient was sensitive to palpation with significant tenderness over the abdomen but no associated features of peritonitis. He collapsed during the imaging examination and became unconscious and asystolic. Cardiopulmonary resuscitation was not successful. The patient died approximately within 2 hours of admission to the hospital. Postmortal examination showed 2800 ml of intraperitoneal blood with clots and a laceration of the lower pole of the spleen. Macroscopic examination of the spleen revealed huge nodular splenomegaly, measuring 21 cm x 19 cm x 5 cm, weighing 755 g. On the cut surfaces, multiple randomly distributed blood-filled cavities ranging from 0,5 to 2 cm in diameter were seen. At microscopic examination, the specimens showed multiple irregular haemorrhagic cyst-like lesions that were not lined by any epithelium or sinusoidal endothelium, consistent with the diagnosis of peliosis lienis. Although the condition is often clinically silent, the forensic pathological significance arises from the differential diagnosis of resultant intraperitoneal haemorrhage and sudden death, mimicking a violent death.

Atraumatic splenic rupture.

Atraumatic splenic rupture (AMR) is a life-threatening condition with a wide range of aetiologies, and it may present with a vague symptomatology. Therefore, AMR can be diagnostically challenging. In this review, we wish to focus on the fact that guidelines only exist for traumatic splenic rupture although they may be applicable for AMR too. In addition, a stringent ABCDE approach for clinical examination may early and reliable diagnose the patients and guide further imaging examination and treatment.

Spontaneous splenic rupture associated with scrub typhus: a case report.

BACKGROUND: Scrub typhus, an acute febrile disease with mild to severe, life-threatening manifestations, potentially presents with a variety of complications, including pneumonia, acute respiratory distress syndrome, cardiac arrhythmias (such as atrial fibrillation), myocarditis, shock, peptic ulcer, gastrointestinal bleeding, meningitis, encephalitis, and renal failure. Of the various complications associated with scrub typhus, splenic rupture has rarely been reported, and its mechanisms are unknown. This study reports a case of scrub typhus-related spontaneous splenic rupture and identifies possible mechanisms through the gross and histopathologic findings. CASE PRESENTATION: A 78-year-old man presented to our emergency room with a 5-day history of fever and skin rash. On physical examination, eschar was observed on the left upper abdominal quadrant. The abdomen was not tender, and there was no history of trauma. The Orientia tsutsugamushi antibody titer using the indirect immunofluorescent antibody test was 1:640. On Day 6 of hospitalization, he complained of sudden-onset left upper abdominal quadrant pain and showed mental changes. His vital signs were a blood pressure of 70/40 mmHg, a heart rate pf 140 beats per min, and a respiratory rate of 20 breaths per min, with a temperature of 36.8 °C. There were no signs of gastrointestinal bleeding, such as hematemesis, melena, or hematochezia. Grey Turner's sign was suspected during an abdominal examination. Portable ultrasonography showed retroperitoneal bleeding, so an emergency exploratory laparotomy was performed, leading to a diagnosis of hemoperitoneum due to splenic rupture and a splenectomy. The patient had been taking oral doxycycline (100 mg twice daily) for 6 days; after surgery, this was discontinued, and intravenous azithromycin (500 mg daily) was administered. No arrhythmia associated with azithromycin was observed. However, renal failure with hemodialysis, persistent hyperbilirubinemia, and multiorgan failure occurred. The patient did not recover and died on the fifty-sixth day of hospitalization. CONCLUSIONS: Clinicians should consider the possibility of splenic rupture in patients with scrub typhus who display sudden-onset abdominal pain and unstable vital signs. In addition, splenic capsular rupture and extra-capsular hemorrhage are thought to be caused by splenomegaly and capsular distention resulting from red blood cell congestion in the red pulp destroying the splenic sinus.

Spontaneous splenic rupture in a neonate: a case report and literature review.

Splenic rupture in a neonate is a rare but potentially fatal condition that may trigger evaluation for child abuse. It is a diagnosis of exclusion that has been reported in the surgical literature but may be underrecognized by pediatric radiologists. We report a case of a newborn with an unremarkable prenatal, delivery, and nursery course who presented with anemia, abdominal distension, and lethargy. Abdominal ultrasound with Doppler and computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis without contrast showed findings of splenic rupture and anoxic brain injury. An extensive workup for traumatic, infectious, coagulopathic, and congenital etiologies was unrevealing, leading to a presumptive diagnosis of spontaneous splenic rupture in a neonate.

Moderate Splenic Injury Caused by Colonoscopy.

Little is known about iatrogenic splenic injury (SI) as an adverse event after colonoscopy. SI is sometimes fatal because of hemorrhaging. We herein report a man who developed SI after colonoscopy. He recovered conservatively. His history of left hydronephrosis and insertion with a maximally stiffened scope were suspected as possible risk factors. Endoscopists should consider the possibility of SI when they encounter patients suffering from left-sided abdominal pain after colonoscopy. Careful interview concerning the medical history and gentle maneuvering around the splenic flexure can help avoid SI.

Infectious Mononucleosis: An Updated Review.

BACKGROUND: Infectious mononucleosis is common among adolescents and young adults. Although the majority of cases resolve spontaneously, life-threatening manifestations, and complications have been recognised. OBJECTIVE: The purpose of this article is to familiarize clinicians with the clinical manifestations, evaluation, diagnosis, and management of infectious mononucleosis. METHODS: A search was conducted in October 2022 in PubMed Clinical Queries using the key terms "infectious mononucleosis" OR "Epstein-Barr virus" OR "EBV". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the aforementioned search was used in the compilation of the present article. RESULTS: Infectious mononucleosis, caused by Epstein-Barr virus, most commonly affects adolescents and adults aged 15 to 24 years. Epstein-Barr virus is transmitted primarily in saliva. Infectious mononucleosis is characterized by a triad of fever, tonsillar pharyngitis, and lymphadenopathy. Fatigue may be profound but tends to resolve within three months. Periorbital and/or palpebral edema, typically bilateral, occurs in one-third of patients. Splenomegaly and hepatomegaly occur in approximately 50% and 10% of cases, respectively. A skin rash, which is usually widely scattered, erythematous, and maculopapular, occurs in approximately 10 to 45% of cases. Peripheral blood leukocytosis is observed in most patients; lymphocytes make up at least 50% of the white blood cell differential count. Atypical lymphocytes constitute more than 10% of the total lymphocyte count. The classic test for infectious mononucleosis is the demonstration of heterophile antibodies. The monospot test is the most widely used method to detect the serum heterophile antibodies of infectious mononucleosis. When confirmation of the diagnosis of infectious mononucleosis is required in patients with mononucleosis-like illness and a negative mono-spot test, serologic testing for antibodies to viral capsid antigens is recommended. Infectious mononucleosis is a risk factor for chronic fatigue syndrome. Spontaneous splenic rupture occurs in 0.1 to 0.5% of patients with infectious mononucleosis and is potentially life-threatening. Treatment is mainly supportive. Reduction of activity and bed rest as tolerated are recommended. Patients should be advised to avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is still present. Most patients have an uneventful recovery. CONCLUSION: Infectious mononucleosis is generally a benign and self-limited disease. Prompt diagnosis is essential to avoid unnecessary investigations and treatments and to minimize complications. Splenic rupture is the most feared complication. As avoiding exposure to EBV is almost impossible, the most effective way to prevent EBV infection and infectious mononucleosis is the development of an effective, safe, and affordable EBV vaccine that can confer life-long immunity.

B-cell hepatosplenic lymphoma presenting in adult patient after spontaneous splenic rupture followed by severe persistent hypoglycaemia: type B lactic acidosis and acute liver failure.

A patient was admitted to hospital with splenic rupture, four 4 days after colonoscopy was performed following one month's intermittent and aggravating abdominal pain. During recovery from splenectomy, the patient developed sudden tachycardic and tachypnoea. A blood sample revealed a very low blood glucose, high lactate and acidaemia.The patient required high-dose continuous intravenous glucose, while the lactate remained elevated. Decreasing consciousness with signs of acute liver failure necessitated transfer to an advanced intensive care unit. The patient's clinical status rapidly deteriorated despite therapeutic intervention. The patient died of multiorgan failure eleven days post-splenectomy. Based on the pathology of the spleen and a post-mortem liver specimen, the patient was diagnosed with a primary extra-nodal B-cell hepatosplenic lymphoma (BCHSL) - an extremely rare form of non-Hodgkin lymphomanon.Splenic rupture followed by lactic acidosis and hypoglycaemia should lead to suspicion of a cancer-mediated Warburg effect, and prompt urgent chemotherapy.

Atraumatic splenic rupture associated with COVID-19.

Atraumatic splenic rupture (ASR) is a rare but life-threatening condition. Several underlying pathologies have been associated with a splenic rupture in the absence of trauma, most often malignant-haematological disorders, viral infections or local inflammatory disorders. The management of ASR is similar to traumatic splenic rupture and includes early risk stratification of patients to determine those eligible for non-operative treatment versus those who need immediate surgical intervention. In this report, we discuss a rare case of a non-operatively managed ASR in an otherwise healthy young patient with SARS-CoV-2 as the likely aetiology. The multisystemic nature of the ongoing novel COVID-19 is evident, but not all manifestations are yet known. This case report underlines the challenge for physicians in terms of recognising and treating emergent complications of this new disease.

Spontaneous rupture of the spleen at full term during pregnancy: a case report.

Spontaneous rupture of the spleen during pregnancy is a rare, fatal disease. This condition is easily misdiagnosed as uterine rupture, placental abruption, or other obstetric diseases; and if a timely diagnosis is not made and effective treatment instituted, serious sequelae rapidly develop, including hemorrhagic shock and maternal and fetal death. Here, we report a case of spontaneous splenic rupture in a woman in her third trimester of pregnancy. Furthermore, through a literature review, we discuss the possible presentations, symptoms, and causes of splenic rupture during pregnancy, in the hope of facilitating the early diagnosis and treatment of this condition.

[Spontaneous splenic rupture. Case report and literature review]. / Ruptura esplénica espontánea. Reporte de caso y revisión de la literatura.

Background: Spontaneous splenic rupture is often life threatening due to delay in diagnosis and treatment. Abdominal pain, Kehr's sign, nausea, bloating, altered consciousness, and intestinal obstruction may be present. In larger splenic lesions, signs of peritonitis and hypovolemic shock are present. Contrast-enhanced computed tomography is the election study. Diagnosis is confirmed by negative viral serology and normal spleen on gross and histopathologic inspection. The most frequent treatment in splenectomy. Clinic case: A 30-year-old male with no medical history presented with generalized abdominal pain accompanied by Kehr's sign. He is diagnosed with ruptured spleen by contrast-enhanced computed tomography and successfully treated with splenectomy. He was discharged 6 days after surgery. Conclusions: Spontaneous rupture of the spleen is uncommon, but with high morbidity and mortality. It must be a differential diagnosis in the face of abdominal and/or chest pain, and the corresponding imaging studies should be carried out if the patient's conditions allow it, or their search during an exploratory laparotomy.

Introducción: la ruptura esplénica espontánea frecuentemente es mortal debido a la demora en el diagnóstico y tratamiento. Se puede presentar dolor abdominal, signo de Kehr, náuseas, distensión abdominal, alteración de la consciencia y obstrucción intestinal. En lesiones esplénicas más grandes, se presentan signos de peritonitis y shock hipovolémico. El estudio de elección es la tomografía computarizada contrastada. El diagnóstico se confirma por serología viral negativa y bazo normal en la inspección macroscópica e histopatológica. El tratamiento más frecuente es la esplenectomía. Caso clínico: paciente hombre de 30 años de edad, sin antecedentes patológicos, con dolor abdominal generalizado, acompañado del signo de Kehr. Es diagnosticado con ruptura de bazo por tomografía computarizada contrastada y tratado exitosamente con esplenectomía. Se egresa a los 6 días postquirúrgicos. Conclusiones: la ruptura espontánea del bazo es poco común, pero con alta morbimortalidad. Debe ser un diagnóstico diferencial ante un dolor abdominal y/o torácico, y realizar los estudios de imagen correspondientes si las condiciones del paciente lo permiten o bien su búsqueda durante una laparotomía exploratoria.

Gray Platelet Syndrome-Unusual Presentation with Spontaneous Splenic Rupture: A Case Report and Literature Review.

Gray platelet syndrome (GPS) is a rare hereditary hemorrhagic disorder characterized by macrothrombocytopenia and the absence of alpha-granules in platelets. Clinically, mild-to-moderate bleeding is the main manifestation, often accompanied by thrombocytopenia, splenomegaly, and myelofibrosis. Here, we present a case of a 15-year-old male patient with a history of hepatosplenomegaly, and thrombocytopenia for 8 years, who presented with sudden generalized abdominal pain. Despite initial suspicion of gastroenteritis, diagnostic imaging revealed an extensive hemoperitoneum. Subsequent genetic testing confirmed the diagnosis of GPS, which had not been previously identified. This case highlights the importance of considering inherited platelet disorders should be considered in adolescents with long-standing thrombocytopenia, and emphasizes the need for thorough evaluation in patients with suggestive symptoms.

Ruptura esplénica después de terapia anticoagulante en un paciente con antecedente de COVID-19: reporte de caso.

We present the case of a 75-year-old man with a history of COVID-19 and splenic infarct treated with enoxaparin, who presented with intense abdominal pain and tomographic findings of free peri-splenic fluid and a hyperdense image in the spleen. An emergency laparotomy was performed, with findings of a splenic rupture at the vascular hilum. Spontaneous splenic rupture is a rare and fatal entity that should be suspected in a patient with history of COVID-19 who presents with acute abdominal pain after the administration of heparin.

Presentamos el caso de un varón de 75 años con antecedente de COVID-19 e infarto esplénico tratado con enoxaparina, quien inició con dolor abdominal intenso y hallazgos tomográficos de líquido libre periesplénico, así como una imagen hiperdensa en el bazo. Fue sometido a laparotomía de urgencia, encontrando una ruptura esplénica a nivel del hilio vascular. La ruptura esplénica espontánea es una condición rara y potencialmente fatal, por lo que se deberá tener un alto índice de sospecha ante un paciente con antecedente de COVID-19 que inicie con dolor abdominal agudo posterior a la administración de heparina.

Complement-Mediated Thrombotic Microangiopathy and Spontaneous Splenic Rupture Associated With Cytomegalovirus Infection.

This is a case report of a previously healthy female patient with complement-mediated thrombotic microangiopathy (TMA) caused by a systemic cytomegalovirus infection that was successfully treated with plasmapheresis, steroids, and parenteral valganciclovir. Complement-mediated TMA is the result of various genetic mutations leading to complement abnormalities with overactivation of alternate complement pathway in response to a triggering infection. She also had splenic rupture without splenomegaly and was managed successfully without splenectomy.