Hrev_master Abstract Spontaneous, atraumatic rupture of the spleen is an uncommon but potentially fatal cause of acute abdominal pain. Splenic abscesses are equally rare and can be a risk factor for spontaneous splenic rupture. We present a 45-year-old man with no past med- ical or surgical history who presented with acute worsening of left upper abdominal pain that had been present for months, who was discovered to have a ruptured spleen. Splenic abscess was discov- ered intra-operatively and was thought to have developed after dental work. Recognizing presenting features of spontaneous splenic rupture and understanding its potential causes, such as splenic abscesses, may prevent delayed or missed diagnosis and guide treatment, which typically includes emergent splenectomy. Introduction Spontaneous, atraumatic splenic rupture is an uncommon but potentially fatal cause of acute abdominal pain. It can be caused by a number of underlying processes, including splenic abscess, which itself is a rare condition with an often-insidious course and high mortality rate. Early recognition of splenic abscess and rup- ture can help to expedite diagnosis and management, which is typ- ically operative. Case Report A 45-years-old male with no past medical or surgical history presented with two months of subjective fevers and intermittent left upper abdominal pain, which had intensified for the past two days. It was associated with multiple episodes of watery emesis for one day and a 25-pounds weight loss over the past month. Six months prior to symptom onset, he had undergone placement of a dental bridge. He took no medications. He had a 20 pack years his- tory of smoking. He was born in Mexico and had been living in the U.S. for the past 15 years. On examination, the patient had a heart rate of 130 beats per minute, blood pressure of 117/66 mmHg, respiratory rate of 22 breaths per minute, oxygen saturation of 94% on room air, and temperature of 37.1 degrees Celsius. He had sinus tachycardia (without extra heart sounds), decreased breath sounds at the left lung base, left upper abdominal tenderness, and splenomegaly. The remainder of his examination was unremarkable. Blood tests were notable for: white blood cell count 30 x cells/mm3 (normal 3.8- 10.9 x103 cells/mm3), bicarbonate 20 mmol/L (normal 22-30 mmol/L), creatinine 1.83 mg/dL (normal 0.6-1.2 mg/dL), and BUN 33 mg/dL (normal 8-24 mg/dL). Liver enzyme and lipase levels were normal. A chest radiograph demonstrated a left lower pleural effusion (Figure 1). A non-contrast CT of the abdomen and pelvis revealed an enlarged, ruptured spleen, with a large hematoma within the spleen (Figure 2). The patient received intra- venous fluids, piperacillin-tazobactam, and metronidazole. Emergent exploratory laparotomy confirmed splenic rupture and the patient subsequently underwent open splenectomy, during which he was found to have a splenic abscess with peritonitis. Intraperitoneal cultures grew Streptococci viridans and Streptococcus gordonii, which are part of the oral flora and atypi- cal causes of splenic abscesses. It was speculated that the dental work he had undergone six months prior was causative. Discussion Splenic abscesses are rare, with an estimated incidence of 0.05-0.07%.1,2 The most common causes are septic emboli from infective endocarditis.3 Other predisposing factors include prior Emergency Care Journal 2021; volume 17:9204 Correspondence: Caleb P. Canders, MD, Department of Emergency Medicine, Santa Clara Valley Medical Center, 751 S Bascom Ave, 95128 San Jose, CA, USA. Tel.: 310.7940785 - Fax: 310.7940599. E-mail: ccanders@mednet.ucla.edu Key words: Splenic abscess; splenic rupture; splenic hemorrhage; splenectomy. Contributions: AAB and CPC drafted the manuscript. AR and SL revised the manuscript critically for important intellectual content. Conflict of interest: No one. This work was not supported by any grant. Availability of data and materials: All data underlying the findings are fully available. Ethics approval and consent to participate: No ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human participants or ani- mals. Informed consent was obtained from the patient included in this study. Consent for publication: The patient gave his written consent to use his personal data for the publication of this case report and any accompany- ing images. Received for publication: 23 June 2020. Accepted for publication: 11 November 2020. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2021 Licensee PAGEPress, Italy Emergency Care Journal 2021; 17:9204 doi:10.4081/ecj.2021.9204 [Emergency Care Journal 2021; 17:9204] [page 31] Splenic abscess leading to spontaneous splenic rupture Annum A. Bhullar,1 Caleb P. Canders,2 Amir Rouhani,1 Steven Lai1 1Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, CA; 2Department of Emergency Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA Non -co mmerc ial us e o nly splenic injuries, immunosuppression, bacteremia, and spread from contiguous organs (e.g. pyelonephritis). The three most common presenting signs of splenic abscesses are fever (90% patients), abdominal pain (31-60% patients), and splenomegaly (50% patients), although only one-third of patients present with the com- plete triad.4 Splenic abscesses in the upper pole may irritate the diaphragm, causing diaphragm elevation, pleural effusion, and pneumonia. Given the vague and insidious nature of symptoms, diagnosis is often delayed or missed; the mean duration of symp- toms from onset until diagnosis is 27 days.4 Leukocytosis is seen in less than half of patients.4 CT and MRI are more accurate than ultrasound at diagnosing splenic abscesses.2,4,5 Staphylococci and Streptococci species are the most common organisms isolated from splenic abscesses; however, anaerobic bacteria, tuberculosis, and fungi have also been reported.6 Blood cultures are negative in more than half of patients.7 Antibiotics should provide coverage against anaerobes and aerobes. Most patients undergo splenectomy, although percutaneous drainage can be successful in some patients.3 Delays in diagnosis have been shown to worsen progno- sis; mortality ranges 0-25% in promptly treated patients and 100% in untreated patients.5,8 Atraumatic splenic rupture is another exceedingly rare diagno- sis that has a mortality of 15%.9 As defined in the surgical litera- ture, cases of “spontaneous rupture” must meet four criteria: i) absence of trauma, ii) absence of disease in other organs that could cause splenic rupture, iii) absence of splenic adhesions/scarring (suggestive of previous rupture), and iv) aside from hemorrhage, the spleen is grossly and histologically normal.10 Causes of sponta- neous splenic rupture include bacterial infections (e.g. splenic abscess, as in our case), viral infections, hematologic malignan- cies, splenic neoplasms, and non-malignant infiltrative processes (e.g. amyloidosis).11 Approximately 95% of patients with sponta- neous splenic rupture have splenomegaly and left upper abdominal tenderness.12 Diaphragmatic irritation may also cause left shoulder pain (Kehr’s sign). CT is the preferred imaging to diagnose splenic rupture and has a sensitivity and specificity greater than 95%.13 Most patients with splenic rupture undergo splenectomy, although transcatheter embolization may be an option in some patients. Conclusions Spontaneous splenic rupture is an uncommon but potentially fatal cause of acute abdominal pain that typically requires emergent operative repair. Patients commonly present with left upper abdom- inal pain and signs of peritonitis and hypovolemic shock. Early recognition and management of spontaneous splenic rupture and its inciting factors, including splenic abscess, can be lifesaving. Case Report Figure 1. Anteroposterior chest X-ray demonstrates an effusion in the left lower lobe (arrow). Figure 2. Coronal (A) and axial (B) computed tomography images show splenomegaly (arrow) with a 6.7 cm by 11.4 cm hematoma within the spleen (star). [page 32] [Emergency Care Journal 2021; 17:9204] Non -co mmerc ial us e o nly References 1. 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Acta Gastroenterol Belg 2019;82:421-6. 9. Renzulli P, Hostettler A, Schoepfer AM, et al. Systematic review of atraumatic splenic rupture. Br J Surg 2009;96:1114- 21. 10. Orloff MJ, Peskin GW. Spontaneous rupture of the normal spleen: a surgical enigma. Int Abstr Surg 1958;106:1-11. 11. Gedik E, Girgin S, Aldemir M, et al. Non-traumatic splenic rupture: report of seven cases and review of the literature. World J Gastroenterol 2009;14:6711-6. 12. Mirvis SE, Soto JA, Shanmuganathan K, et al. Problem Solving in Emergency Radiology. Saunders. 13. Jeffrey RB, Laing FC, Federle MP, et al. Computed tomogra- phy of splenic trauma. Radiology 1981;141:729-32. Case Report [Emergency Care Journal 2021; 17:9204] [page 33] Non -co mmerc ial us e o nly