Hemoperitoneum from splenic rupture in an expatriate.

Splenic rupture with hemoperitoneum represents a life-threatening surgical emergency. Malaria should be highly suspected as the probable underlying disease in returning travellers, expatriates, or recent immigrants from endemic countries. Malarial complications involving the spleen occur even with appropriate prophylaxis or during antimalarial therapy. Among them, splenic infarction has a favourable course and is treated conservatively, whereas life-threatening rupture requires immediate or delayed splenectomy. Computed tomography (CT) allows confident differentiation between these two complications by identifying ruptured spleen with clotted hematoma and associated high-density peritoneal effusion; furthermore, CT allows differential diagnosis from other causes of spontaneous hemoperitoneum.

CASE DESCRIPTION

A 42-year-old Italian man, who had been living in Nigeria because of his job since two years, was urgently repatriated following diagnosis of acute Plasmodium falciparum malaria. Fourteen days after anti-malarial treatment started, with quick resolution of fever, he suddenly complained of acute left flank pain.

At emergency department (ED) admission, his vital parameters appeared stable. Physical examination revealed tender left hemiabdomen without frank peritonism. Laboratory tests disclosed severe anemia (hemoglobin 7.7 g/dL), moderate leukocytosis, markedly elevated C-Reactive Protein (232 mg/L), plasma D-Dimer (2188 ug/L), lactic dehydrogenase (654 IU/L) and creatine kinase (1255 IU/L); platelet count and coagulation assays were within normal limits. Rapid blood assay tested positive for P. falciparum antigen, with negative blood cultures for bacteria and parasites.

Prompt investigation with multi-detector CT [Figure 1] allowed confident diagnosis of diffuse, moderately hyperdense peritoneal effusion consistent with hemoperitoneum and splenomegaly with hyperdense, stratified subcapsular and perisplenic clotted hematoma. Bilateral pleural effusion and lung base atelectasis were also present.

Figure 1

Axial unenhanced (a) and contrast-enhanced (b) images of the upper abdomen reveal splenomegaly with stratified subcapsular and perisplenic hyperdensity consistent with ruptured splenomegaly and clotted hemorrhage. Axial unenhanced image of the pelvis (c) and post-contrast panoramic coronal-reformatted image (d) show moderately hyperdense (30-40 HU) effusion (asterisks) occupying the Douglas pouch as well as other peritoneal compartments

Urgent laparotomic surgery confirmed abundant hemorrhagic peritoneal effusion without detectable active bleeding. Splenomegaly with multiple blood clots was resected. Pathology specimen reported 850-g enlarged spleen measuring 17×14×8 cm after fixation, with large capsular interruption and underlying hematoma. Histologically, diffuse parenchymal hemorrhage and markedly hypertrophic red pulp were observed, without follicular structure abnormalities nor signs of malignancy.

DISCUSSION

Although very uncommon, spontaneous (non-traumatic) hemoperitoneum is a life-threatening condition that generally represents a surgical emergency and may prove fatal even if promptly diagnosed and appropriately treated. Its differential diagnosis includes bleeding from liver (mostly hepatocellular adenoma or carcinoma rather than metastases) or kidney (particularly angiomyolipomas) tumors, splenic rupture, visceral aneurysms or pseudo-aneurysms, deep abdominal varices from portal hypertension, excessive anticoagulant treatment, hemodialysis and gynaecological disorders such as ovarian cyst or ectopic pregnancy rupture.[12]

Because of its widespread availability and extreme acquisition speed, CT currently performed on multi-detector scanners represents the mainstay diagnostic modality to investigate patients presenting to with acute abdomen and signs of hemodynamic instability. At CT, hemoperitoneum is heralded by higher-than-water density (measuring 30-45 Hounsfield Units, HU) peritoneal effusion, whereas the even more hyperdense (45-70 HU) “sentinel” blood clot is usually observed nearest to the site of hemorrhage; sometimes contrast extravasation indicating active bleeding may be detected, a finding that indicates the necessity for emergency surgical or interventional treatment. As in this case, CT confidently identifies the spleen as the injured organ. Splenic rupture most usually occurs during various systemic infections, mostly including malaria, cytomegalovirus and Epstein-Barr virus, so a quick but thorough history and laboratory search for infection is required when spontaneous splenic rupture is diagnosed. Uncommonly, rupture may complicate diffuse splenic infiltration such as in amyloidosis or Gaucher's disease, or leukemic, lymphomatous, or malignant disorders.[12]

Since malaria still represents a major medical problem worldwide (particularly in tropical and subtropical regions of Asia and Africa and parts of the Americas), because of expanding travel and Plasmodium resistance clinicians in the Western world are increasingly confronted with diagnosis and management of malaria and its complications. Notably, malaria ranks first among causes of fever among travellers coming back from the tropics. When confronted with acute abdomen with signs of shock in a recent immigrant, tourist or expatriate returning from an endemic nation, malaria complicated by splenic rupture should be strongly suspected.[34] During the course of acute malaria, splenic changes range from asymptomatic, palpable enlargement to serious complications such as infarction, rupture, hematoma, or abscess that occur more frequently in non-immune adults such as Western travellers, often despite appropriate prophylaxis or during anti-malarial therapy. Whereas splenic infarction has a favourable course and needs to be treated conservatively to avoid postoperative and asplenic morbidity, splenic rupture represents a life-threatening emergency with a non-negligible mortality (22%) and usually requires immediate or delayed surgical splenectomy.[3-5] Since clinical, laboratory, and ultrasound findings are usually insufficient to correctly differentiate these two complications, patients coming from overseas with suspected or confirmed malaria presenting to with enlarging tender splenomegaly, left upper abdomen, and/or pleuritic lower chest pain and variable-degree hemodynamic compromission require prompt imaging assessment with contrast-enhanced multi-detector CT that allows confident diagnosis and correct therapeutic choice.[12]