The potential for splenic injury during left sided thoracentesis or percutaneous renal biopsy is well known, its occurrence has been rarely reported1. In a series of 244 incidental splenectomies, only one was secondary to left thoracentesis2. Each year about 600 new cases of extrinsic allergic alveolitis are diagnosed in the UK3. Lung biopsy is an important diagnostic tool for diffuse lung disease. Others include bronchoalveolar lavage and high resolution computed tomography3. We present a case of delayed splenic rupture following percutaneous lung biopsy, which required urgent laparotomy.
Case Report
A 48-year-old gentleman presented with left upper quadrant pain and shortness of breath for eight hours prior to admission. There was no history of trauma, haematological or storage diseases. The patient underwent a left lung biopsy two months earlier which had led to the diagnosis of extrinsic allergic alveolitis.On examination, he was comfortable and haemodynamically stable. Respiratory and cardiovascular examinations were unremarkable, abdomen was soft and non-tender. Initial haematological investigations, cardiac enzymes and electrocardiogram were normal. A provisional diagnosis of inferior wall myocardial infarction was made.He became progressively hypotensive and developed abdominal distension with left upper quadrant tenderness. Two scars were noted, one over 6th and the other over 8th intercostal spaces.Urgent computed tomography of abdomen and pelvis revealed complex fluid collection around the spleen and free intraperitoneal fluid (fig 1). At emergency laparotomy, 2.5 litres of intraperitoneal blood was removed. A large clot was identified under left dome of diaphragm. A small-healed wound over the lateral surface of the spleen was identified. No active bleeding was evident and the findings were consistent with those of a ruptured subcapsular splenic haematoma. Postoperative recovery was uneventful and the patient was discharged on day seven.
Discussion
This case highlights the delay with which an iatrogenic splenic injury can present. The most important indicator in this case, which could relate to splenic injury, was a scar near the splenic region following lung biopsy. Clinical problems after splenic rupture have been classified into three groups characterized by the delay in presentation and type of symptoms4. Group one: acute ruptured spleen, Group two: delayed ruptured spleen, and Group three: occult ruptured spleen. Our case was group two, with delayed presentation two months after injury.Computed tomography is the gold standard for investigating splenic injuries. Grading scales based on computed tomography findings can predict the likelihood of successful non-operative management, which is often possible if the splenic hilum is intact (even when capsular disruption is present)5. However, due to haemodynamic instability in this case, percutaneous drainage was not performed. As new cases of diffuse lung disease are being investigated, physicians should be increasingly aware of the possibility of splenic injury after lung biopsy. Splenic injury should be considered if haemodynamic instability occurs even after two months of lung biopsy.