Spontaneous Splenic Rupture in a 21-year old Male Patient

Patient: H.M. 21year old, male, single, Filipino from Sara Iloilo

Chief Complaint: Cough.

Six days prior to admission: Patient had productive cough with whitish phlegm,
associated with difficulty of breathing and undocumented fever.

Three days prior to admission: He sought consult to a private physician due to

persistence of symptoms, and was given the following meds:

 Sultamicillin tosylate 750mg/tab, twice a day for 7days,

 Salbutamol syrup 2mg/5mL,
 Montelukast 10mg/tab 1 tablet at bedtime, and
 Formoterol+Budesonide 160mcg/4.5mcgpuff, 2 puffs twice a day.

Relief of fever was noted but cough and difficulty of breathing was persistent, thus
patient was advised hospital admission.

Past Medical History:

Patient has Bronchial Asthma since childhood, but has no maintenance

medications.

Personal, Social and Environmental History:

He is a student, non-smoker, and non-alcoholic beverage drinker.

His maternal grandfather had history of Pulmonary TB and completed 6months of DOTS
treatment.

Physical Examination:

He was conscious and ambulatory.

Weight: 40 kg Height: 5’3” Temp. 37.5˚C BP: 90/60 CR: 95 beats/minute

Slightly tachypneic with respiratory rate of 22 cycles per minute
Oxygen saturation: 97% at room air
Pulmonary Findings: fine rales at left basal lung
Abdomen: Soft and non-tender with nonpalpable spleen and normal liver span
Laboratory Results:

Haemoglobin: 83g/L WBC count:10.60 x109/L.

Protime: 70% with INR of 1.26 He then received Vitamin K 1 ampule every eight hours for
three doses.
Chest Xray: Infiltrates mid to base with consolidation, left lower lung and minimal pleural
effusion, left.

He was admitted and started on:

Piperacillin-Tazobactam 4.5gm IV Q8h and

Azithromycin 500mg/tab OD,

and received 2u of PRBC transfusion for correction of anemia.

Chest Ultrasound on second hospital day:

 Consolidation of left lung base and minimal left pleural effusion approximately
2cc in volume.
 There was a significant incidental finding of splenomegaly with several slightly,
and complex hypoechoic foci noted in the parenchyma. A mass is noted along
its superior aspect (measuring 3.5x7.1x7.1cm), with thick fluid communicating
with the upper portion of the spleen.

He was then started on Clindamycin 300mg/cap 1cap QID and referred to a

gastroenterologist.

Repeat CBC: haemoglobin - 113g/L (from 83) after two units of packed red blood cell
transfusion.

Repeat protime was 64% (from 70%) with INR of 1.33, so Vitamin K was continued every
eight hours.

Further imaging studies were done and CT scan of the chest and upper abdomen:

 Irregular border nodule, right upper lobe.

 Left basal lung infiltrates with consolidation
 Splenomegaly with complex hypoechoic foci noted in the parenchyma, a mass
with thick fluid
 Subcarinal, left hilar and paraaortic lymphadenopathies
 Figure 1. A. Chest X-ray upon admission B. Chest CT scan

On the 7th hospital day, patient had stable vital signs, afebrile, non-dyspneic,
occasional productive cough, and fine rales at left base. Sputum culture only revealed
light growth of Candida famata and patient was started on Fluconazole 150mg/tab,
OD. He was subsequently referred to infectious disease service. Patient underwent
immune status screening which yielded unremarkable results.
Figure 2. CT scan of abdomen with contrast A. Coronal section B. axial section

A B

Ultrasonograhic re-evaluation of the spleen was done, with note of splenomegaly

and progression of splenic hypoechoic foci in the upper portion of the spleen with
resolution of complex lesion at the medial aspect of the spleen. There were still presence
of hypoechoic splenic nodules and retroperitoneal lymphadenopathies.

He was referred to Department of Surgery for co-management and possible

surgical intervention, and was scheduled for splenectomy. Repeat protime was 63% with
INR of 1.34. He was co-managed with Hematology service and was given 1unit of fresh
frozen plasma (FFP) prior to OR, with 3u FFP standby for transfusion post-surgery.

Patient underwent total splenectomy. The operation was uneventful and patient
was stable post-operatively, with no note of significant surgical complications. He
received Pneumococcal, Meningococcal and hemophilus influenza B vaccine and was
discharged 1 week after surgery.

A B

Figure 3. Perieoperative findings. (A) Intact diaphragm without rupture but with
note of fibrosis. (B) splenomegaly

Specimen was sent for biopsy.