Spontaneous Rupture of the Spleen during Malaria: A Conservative Treatment Approach May Be Appropriate

Sir—Spontaneous rupture of the spleen is a rare complication of malaria. We report a case of splenic rupture that was successfully treated with a conservative approach. A formerly healthy 23-year-old man was admitted to the hospital with a 2-week history of fever, myalgia, and diarrhea, which occurred after a stay of several weeks in Kenya. The patient had not received malaria prophylaxis. The initial physical examination showed that he was severely ill, with a body temperature of 39.8°C, blood pressure of 99/41 mmHg, and a heart rate of 126 beats/min. There was no abdominal tenderness or rigidity, and the spleen was not enlarged. Laboratory tests revealed a WBC count of 5.4 × 109 cells/L, a hemoglobin level of 128 g/L, a platelet count of 27 × 109 platelets/L, and parasitemia (Plasmodium falciparum percentage, 2.2%). Quinine treatment was administered intravenously. Two days after admission to the hospital, the patient became dyspneic, with a respiratory rate of 35 breaths/min; the patient had an arterial partial pressure of oxygen of 10 kPa while breathing 3 L of oxygen/min. A chest radiograph showed bilateral infiltrates, and the left ventricular ejection percentage was 40%. Noninvasive ventilation and diuretic therapy promptly resolved these anomalies. On day 4 of hospitalization, abdominal tenderness and enlargement appeared, associated with a drop in the hemoglobin level to 62 g/L. Abdominal CT showed splenomegaly (maximum spleen diameter, 23 cm), with 2 areas of rupture, a contained hematoma, and an abundant hemoperitoneum (figure 1). Because hemodynamic parameters were stable, a conservative treatment approach was selected. The patient was discharged from the hospital 19 days after admission, after abdominal CT demonstrated that the perisplenic hematoma and the hemoperitoneum had decreased. The patient was regularly followed up for 8 months. The last CT scan, performed 1 month after admission, showed only a small anterior splenic hypodensity. Eight months after admission, the patient had no abdominal symptoms, and the findings of ultrasonography were normal. Abdominal CT scan showing a splenic hematoma and hemoperitoneum Although spleen enlargement is a very common feature of malaria, the incidence of spontaneous splenic rupture is not well known; it ranges from 0% to 2%. Using the Medline database, we found 19 cases reported in the literature since 1960 [1, 2]. Formation and subsequent rupture of an initially contained hematoma is believed to be the usual mechanism of splenic rupture. In the present case, polypnea and the use of positive-pressured noninvasive ventilation may have played a role in the formation of a splenic hematoma. To our knowledge, a very limited number of cases of spontaneous splenic rupture during malaria have been treated with a nonsurgical approach [2, 3]. Splenectomy has always been considered the treatment of choice to control bleeding related to splenic rupture, but the procedure leads to loss of the immunologic function of the spleen, resulting in an increased susceptibility to infections. In the case of splenic trauma, nonsurgical management is the prevailing treatment approach when hemorrhagic shock is absent [4]. Few data are available concerning infection-related rupture of the spleen. However, the significant morbidity and mortality and the increased risk of complicated or fatal disease from future exposure to malaria that are associated with splenectomy should lead to the use of a conservative treatment approach whenever possible. Potential conflicts of interest. All authors: no conflicts.