Letter to the Editor
Emergency splenectomy after spontaneous rupture in a patient with malaria
Esplenectomía de urgencia tras rotura espontánea de bazo en paciente afectado de malaria
José Luis García Galocha
, Alejandra García Botella, Antonio Jose Torres García
Corresponding author
Cirugía General y Digestiva, Hospital Clínico San Carlos, Madrid, Spain
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The mechanism is diverse and includes a significant number of diseases. We report the case of an atraumatic splenic rupture in a patient with malaria.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 44-year-old man with no comorbidities who, after a trip to Borneo, came to our centre with a 48-h history of flu-like symptoms, accompanied by mild generalized abdominal pain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During his stay in the hospital ward, the patient maintained daily fever spikes, with no other abnormalities on examination. Laboratory tests revealed leukocytopenia and thrombocytopenia. HIV, HBV, HCV and dengue serologies were negative. In addition, a peripheral blood smear was requested, which identified <span class="elsevierStyleItalic">Plasmodium knowlesi (P. knowlesi)</span>, so antimalarial treatment with atovaquone plus proguanil was initiated.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite treatment and haemodynamic and transfusion support, the patient began to present hypotension and progressive anaemia in the hours that followed, so urgent surgical treatment was decided, and a routine splenectomy was performed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The surgical specimen had 2 solutions of continuity in addition to a significant subcapsular haematoma. Anatomical pathology revealed lymphoid infiltration of the trabecular veins, as well as merozoites.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Spontaneous splenic rupture has an incidence of less than 1%, with few reports since the initial description by Rokitansky in 1861 and occurs most often in a diseased spleen due to various haematological, tumoral, local and infectious causes.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The incidence of rupture in the context of an acute <span class="elsevierStyleItalic">Plasmodium</span> infection represents around 2% of all spontaneous cases, with a mortality that can reach 20%.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It usually occurs in middle-aged men and mainly in the context of <span class="elsevierStyleItalic">Plasmodium falciparum</span> or <span class="elsevierStyleItalic">vivax</span> infections, with this being the first case described after an infection by <span class="elsevierStyleItalic">P. knowlesi</span>.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It has an incubation period of approximately 2<span class="elsevierStyleHsp" style=""></span>weeks, the main manifestation being a flu-like illness usually associated with a variable degree of abdominal pain. Kehr’s sign (left shoulder pain due to phrenic nerve irritation) is typical, although uncommon.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The pathophysiology of parasitic splenic rupture is not clear, postulating 3 fundamental mechanisms, which lead to extreme splenic friability:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Direct endothelial damage by the binding of parasitic membrane proteins (PfEMP1).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Sinusoidal blood stasis due to increased lymphatic tissue.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Multifactorial anaemia due to erythrocytic parasitosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In terms of diagnosis, initially a complete blood test should be undertaken, in which thrombocytopenia and anaemia are common. This would be in addition to a thick blood film, which will confirm the presence of the parasite.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Imaging tests are necessary, with the gold standard being IV contrast-enhanced abdominal CT. However, it should be noted that it is reserved for stable patients.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given a suspicion of infectious splenic rupture, the patient should be managed in the same way as for a traumatic rupture. If the patient is unstable, FAST ultrasound and exploratory laparotomy will be performed if positive, while if stable, diagnostic confirmation is required with an intravenous contrast scan.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Splenic preservation in the case of a parasitized ruptured spleen is unclear.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In cases of stable patients with a grade <span class="elsevierStyleSmallCaps">I</span> rupture, splenectomy may not be necessary with the correct antimalarial treatment and close monitoring. However, it should be noted that the degree of radiological splenic lesion does not correlate with progression to conservative treatment.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">However, splenectomy is still considered the standard treatment in patients with progressive anaemia despite correct antimalarial treatment or in those who are hemodynamically unstable.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although an uncommon aetiology for splenic rupture, it should be suspected in patients from endemic areas; with fever, left flank pain and progressive anaemia with or without haemodynamic instability.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García Galocha JL, García Botella A, Torres García AJ. Esplenectomía de urgencia tras rotura espontánea de bazo en paciente afectado de malaria. Med Clin (Barc). 2022;158:447–448.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous rupture of malarial spleen presenting as hemoperitoneum: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N. Gupta" 1 => "P. Lal" 2 => "A. Vindal" 3 => "N.S. Hadke" 4 => "N. 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