Splenic rupture

Editor – We read with interest the case of ‘Spontaneous splenic rupture secondary to dabigatran’ by Carey and Nelatur.¹ Drug related atraumatic splenic rupture (ASR) is well described and accounts for 9–33% cases with anticoagulants being the main group of drugs implicated.²

The presentation of ruptured spleen can be delayed and may occur even after trivial injury.³ Could it be considered in this case?

Recently we saw a 20-year-old amateur boxer in Vanuatu who presented in the evening to the emergency department in shock. He complained of general weakness having collapsed getting off a bus. Initially he gave no history of trauma and had no abdominal pain. He had been training that afternoon using the heavy bag but not sparring. On examination he was afebrile, pale, pulse of 78 beats/min, blood pressure of 80/70 mmHg and oxygen saturation at 95%. Abdominal examination was unremarkable and rectal examination revealed no melaena. Shock secondary to concealed haemorrhage was considered. Further questioning revealed that he had fallen out of a tree and hit his left side one month previously. A diagnosis of ruptured spleen was made and was confirmed at laparotomy where he underwent splenectomy. He made a full recovery. The absence of tachycardia was initially attributed to his being a well conditioned athlete. However, relative bradycardia has been described in splenic rupture and is associated with poorer outcome.⁴

Conservative management of ruptured spleen is the preferred option particularly in malaria endemic areas. We have seen two cases of ASR complicating vivax malaria, both fatal. This is the single major cause of ASR worldwide. Over 80% require surgical management and it has a 22% mortality rate.⁵ We have seen one case of ASR complicating tuberculosis in Australia successfully treated with splenectomy after a trial of conservative management failed.⁶