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.