Discussion:

Spontaneous rupture of the spleen is a rare etiology with a mortality rate ranging from 15% to 70% depending upon the cause. Orloff and Peskinin 1958 described diagnostic criteria for spontaneous rupture of the spleen that include: the absence of previous trauma, the absence of pathology that could affect the spleen, the absence of splenic adhesions, and the need for a normal spleen on anatomical, histological and infectious workup.[7] Causes of spontaneous splenic rupture include malaria, amyloidosis, infectious mononucleosis, rupture of a splenic aneurysm, malignancy-induced coagulopathy, bleeding disorders, and anticoagulant use. Some authors have reported spontaneous rupture of the spleen due to exostosis of the 10th. [7] The exact mechanism behind spontaneous rupture of the spleen is not known, but several mechanisms have been described in Literature as a hypothesis: Cellular hyperplasia and venous engorgement leading to congestion and increased tension upon the capsule, vascular occlusion, and hyperplasia resulting in thrombosis or ischemia and occasional increase in intra- abdominal pressure with coughing, laughing, sneezing and vomiting leading to increase stress on the abnormal spleen. All these factors combined can lead to subcapsular hematoma formation and rupture of the splenic capsule. Spontaneous splenic rupture happens in the acute phase of the infection, as in the recurrent or chronic malaria infection because spleen enlargement is gradual and tension on the capsule is less pronounced. Moreover, fibrous tissue from the previous infection prevents the development of this complication [8]. Clinical features can be divided into main categories. Systemic features due to intra- abdominal loss manifest as tachycardia, tachypnoea, hypotension, oliguria, and altered mental, and local features due to peritoneal irritation manifest as left upper quadrant pain that radiates to the shoulder (Kehr’s sign), abdominal tenderness and guarding on examination. Local abdominal symptoms may be absent in up to half of the cases causing delayed or missed diagnosis with potentially fatal complications and so a high index of clinical susception is required to detect spontaneous splenic rupture, especially in endemic areas [8]. Abdominal ultrasound can detect splenic rupture, subcapsular hematoma, peri splenic collections, and free fluid (blood in the peritoneal cavity. But Computerized tomography (CT) scan of the abdomen can spot the smallest hematoma before the development of splenic rupture and a CT scan is the most useful in the diagnosis and monitoring of patients in whom conservative management is warranted. [6] Management of spontaneous rupture of the spleen can be divided into conservative management and surgical management. Conservative management can be by administration of anti-malarial medications as per local guidelines, observation in the hospital with strict bed rest for up to 14 days, administration of fluids and blood products as required, and monitoring of patient vital signs. Assessment of the spleen by CT scan is required to monitor healing. Splenectomy is reserved for patients who have uncontrollable bleeding, hemodynamic instability, and shock that is not responding to fluid resuscitation. Some authors have described embolization of the splenic artery as an alternative, but it requires well-equipped facilities. [3] . Our case presented with acute shock and hemodynamic instability that did not respond to resuscitation, which warranted surgical intervention. historically, splenectomy was the treatment of choice in all cases of malarial splenic rupture. But recently some authors have advocated conservative treatment as an alternative, especially in hemodynamically stable to prevent the adverse effects of splenectomy [5]. Conclusion: Spontaneous splenic rupture due to malaria is an uncommon complication even in an endemic area and it requires a high index of clinical suspicion, especially in patients having malarial infection presenting with abdominal pain, and hemodynamic instability. Attempts to manage the case conservatively can be offered to patients, but splenectomy should always be done when conservative management has failed or become contra-indicated.