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Red-flag Syncope: Spontaneous Splenic Rupture
IMAGES IN RADIOLOGY Robert G. Stern, MD, Section Editor
Red-flag Syncope: Spontaneous Splenic Rupture Ami Schattner, MD,a,d Adi Meital, MD,b,d Eliezer Mavor, MDc,d a
Department of Medicine, bDepartment of Radiology, and cDepartment of Surgery, Kaplan Medical Center, Rehovot, and dHebrew University and Hadassah Medical School, Jerusalem, Israel.
PRESENTATION After fainting in the lavatory, a healthy 59-year-old woman was taken to the hospital, where she would ultimately receive an unexpected diagnosis. On admission, she reported that she had been experiencing epigastric pain radiating to the left shoulder for several hours.
low blood pressure ( 100 mm Hg) correctly stratified this patient’s syncope as high risk.1 Although not specific, the presence of neutrophilia can be regarded here as a marker for the severity of bleeding.2 Splenic rupture may occur without blunt abdominal trauma. Usually, it takes place in the setting of an infectious or neoplastic disease involving the spleen, though other etiologies may underlie these rare, so-called pathologic,
ASSESSMENT The patient’s physical examination was remarkable for pallor, blood pressure of 86/45 mm Hg that later increased to 100/60 mm Hg, and epigastric tenderness. An electrocardiogram, chest x-ray, and abdominal x-ray were each normal. Laboratory tests showed that her hemoglobin was 9.5 g/dL, and her neutrophil count was 14.5 109 cells/L. A rectal examination and gastroscopy were unremarkable except for a known diaphragmatic hernia, which was treated with pantoprazole. The patient’s hemoglobin dropped to 6.6 g/dL over 14 hours, and contrast computed tomography revealed free fluid in the abdomen, a large hematoma around the spleen, and active arterial bleeding (Figure). She had no history of trauma. Total splenectomy was immediately performed.
DIAGNOSIS While the patient’s spleen was normal in size (144 g) and results from histology and immunostaining were normal, it was ruptured and a massive subcapsular hematoma was evident. Few causes of syncope are more immediately lifethreatening—and more difficult to diagnose—than spontaneous occult acute arterial bleeding in a previously healthy patient. Her low initial hematocrit (< 30%) and persistently Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and wrote the paper. Requests for reprints should be addressed to Ami Schattner, MD, Professor and Head, Department of Medicine, Kaplan Medical Center, POB 1, Rehovot 76100, Israel. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.02.024
Figure Coronal contrast-enhanced computed tomography showed a large perisplenic hematoma (black arrows) with active bleeding (dashed arrow). Free peritoneal fluid was present (white arrows), including fluid in a large diaphragmatic hernia (white arrowheads).
502 Table
The American Journal of Medicine, Vol 127, No 6, June 2014 Main Associated Conditions of Spontaneous Splenic Rupture*
Infectious Epstein-Barr virus or cytomegalovirus mononucleosis; dengue; human immunodeficiency virus; other viral infections; malaria; kala-azar; babesiosis; ricketsial or bartonella infection; tuberculosis; brucellosis; infective endocarditis or splenitis of various blood-borne infections; splenic abscess (eg, typhoid fever) Neoplastic Lymphoma, leukemia, plasma-cell dyscrasias, malignant histiocytosis; primary splenic tumor (eg, angiosarcoma); splenic metastases (rare) Benign splenic pathology Cyst; peliosis; angiomatosis; splenic artery aneurysm; splenic vein thrombosis Coagulopathy Factor deficiency; Chronic hemodialysis; anticoagulant treatment Varia Metabolic storage disease (eg, Gaucher); autoimmune disease; pancreatitis; sarcoidosis; portal hypertension; pregnancy; forceful vomiting or cough None Normal spleen in a healthy patient *Based on isolated case reports and a few small series identified in our PubMed search of articles on ’spontaneous rupture’ or ’nontraumatic rupture’ AND spleen, published in the English language, with abstracts.
ruptures (Table).3,4 Nontraumatic splenic rupture in a patient with an apparently healthy spleen also has been reported, but fortunately, this is an exceedingly unusual event.5 Nevertheless, its occurrence in soldiers and other fit young people highlights the existence of true idiopathic splenic rupture of unknown pathogenesis.5
MANAGEMENT Our patient’s signs and symptoms were investigated and diagnosed rapidly. After splenectomy, she made a complete recovery, and she has remained well over 4 years of follow-up. Our report emphasizes the need for heightened awareness of spontaneous splenic rupture. Although uncommon, it can be fatal and thus demands swift intervention. Once suspicions are raised for this condition, CT
is the mainstay of diagnosis and should be performed without delay.3,5
References 1. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43:224-232. 2. Chalasani N, Patel K, Clark WS, Wilcox CM. The prevalence and significance of leukocytosis in upper gastrointestinal bleeding. Am J Med Sci. 1998;315:233-236. 3. Debnath D, Valerio D. Atraumatic rupture of the spleen in adults. J R Coll Surg Edinb. 2002;47:437-445. 4. Aubrey-Bassler FK, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emerg Med. 2012;12:11. 5. Rice JP, Sutter CM. Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report. J Med Case Rep. 2010;4:353.
Red-flag Syncope: Spontaneous Splenic Rupture Ami Schattner, MD,a,d Adi Meital, MD,b,d Eliezer Mavor, MDc,d a
Department of Medicine, bDepartment of Radiology, and cDepartment of Surgery, Kaplan Medical Center, Rehovot, and dHebrew University and Hadassah Medical School, Jerusalem, Israel.
PRESENTATION After fainting in the lavatory, a healthy 59-year-old woman was taken to the hospital, where she would ultimately receive an unexpected diagnosis. On admission, she reported that she had been experiencing epigastric pain radiating to the left shoulder for several hours.
low blood pressure ( 100 mm Hg) correctly stratified this patient’s syncope as high risk.1 Although not specific, the presence of neutrophilia can be regarded here as a marker for the severity of bleeding.2 Splenic rupture may occur without blunt abdominal trauma. Usually, it takes place in the setting of an infectious or neoplastic disease involving the spleen, though other etiologies may underlie these rare, so-called pathologic,
ASSESSMENT The patient’s physical examination was remarkable for pallor, blood pressure of 86/45 mm Hg that later increased to 100/60 mm Hg, and epigastric tenderness. An electrocardiogram, chest x-ray, and abdominal x-ray were each normal. Laboratory tests showed that her hemoglobin was 9.5 g/dL, and her neutrophil count was 14.5 109 cells/L. A rectal examination and gastroscopy were unremarkable except for a known diaphragmatic hernia, which was treated with pantoprazole. The patient’s hemoglobin dropped to 6.6 g/dL over 14 hours, and contrast computed tomography revealed free fluid in the abdomen, a large hematoma around the spleen, and active arterial bleeding (Figure). She had no history of trauma. Total splenectomy was immediately performed.
DIAGNOSIS While the patient’s spleen was normal in size (144 g) and results from histology and immunostaining were normal, it was ruptured and a massive subcapsular hematoma was evident. Few causes of syncope are more immediately lifethreatening—and more difficult to diagnose—than spontaneous occult acute arterial bleeding in a previously healthy patient. Her low initial hematocrit (< 30%) and persistently Funding: None. Conflict of Interest: None. Authorship: All authors had access to the data and wrote the paper. Requests for reprints should be addressed to Ami Schattner, MD, Professor and Head, Department of Medicine, Kaplan Medical Center, POB 1, Rehovot 76100, Israel. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.02.024
Figure Coronal contrast-enhanced computed tomography showed a large perisplenic hematoma (black arrows) with active bleeding (dashed arrow). Free peritoneal fluid was present (white arrows), including fluid in a large diaphragmatic hernia (white arrowheads).
502 Table
The American Journal of Medicine, Vol 127, No 6, June 2014 Main Associated Conditions of Spontaneous Splenic Rupture*
Infectious Epstein-Barr virus or cytomegalovirus mononucleosis; dengue; human immunodeficiency virus; other viral infections; malaria; kala-azar; babesiosis; ricketsial or bartonella infection; tuberculosis; brucellosis; infective endocarditis or splenitis of various blood-borne infections; splenic abscess (eg, typhoid fever) Neoplastic Lymphoma, leukemia, plasma-cell dyscrasias, malignant histiocytosis; primary splenic tumor (eg, angiosarcoma); splenic metastases (rare) Benign splenic pathology Cyst; peliosis; angiomatosis; splenic artery aneurysm; splenic vein thrombosis Coagulopathy Factor deficiency; Chronic hemodialysis; anticoagulant treatment Varia Metabolic storage disease (eg, Gaucher); autoimmune disease; pancreatitis; sarcoidosis; portal hypertension; pregnancy; forceful vomiting or cough None Normal spleen in a healthy patient *Based on isolated case reports and a few small series identified in our PubMed search of articles on ’spontaneous rupture’ or ’nontraumatic rupture’ AND spleen, published in the English language, with abstracts.
ruptures (Table).3,4 Nontraumatic splenic rupture in a patient with an apparently healthy spleen also has been reported, but fortunately, this is an exceedingly unusual event.5 Nevertheless, its occurrence in soldiers and other fit young people highlights the existence of true idiopathic splenic rupture of unknown pathogenesis.5
MANAGEMENT Our patient’s signs and symptoms were investigated and diagnosed rapidly. After splenectomy, she made a complete recovery, and she has remained well over 4 years of follow-up. Our report emphasizes the need for heightened awareness of spontaneous splenic rupture. Although uncommon, it can be fatal and thus demands swift intervention. Once suspicions are raised for this condition, CT
is the mainstay of diagnosis and should be performed without delay.3,5
References 1. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco syncope rule to predict patients with short-term serious outcomes. Ann Emerg Med. 2004;43:224-232. 2. Chalasani N, Patel K, Clark WS, Wilcox CM. The prevalence and significance of leukocytosis in upper gastrointestinal bleeding. Am J Med Sci. 1998;315:233-236. 3. Debnath D, Valerio D. Atraumatic rupture of the spleen in adults. J R Coll Surg Edinb. 2002;47:437-445. 4. Aubrey-Bassler FK, Sowers N. 613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review. BMC Emerg Med. 2012;12:11. 5. Rice JP, Sutter CM. Spontaneous splenic rupture in an active duty Marine upon return from Iraq: a case report. J Med Case Rep. 2010;4:353.