Year : 2010 | Volume
: 21 | Issue : 4 | Page : 712--714
Spontaneous rupture of the spleen: A rare complication in a patient with lupus nephritis on hemodialysis
Quaid J Nadri, Osman Alfurayh
Department of Medicine, Division of Nephrology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Quaid J Nadri
King Faisal Specialist Hospital and Research Center, Department of Medicine, MBC # 46, P.O. Box 3354, Riyadh 11211
Rupture of the spleen is a life threatening condition. We report a 40-year-old female patient, a known case of lupus nephritis receiving hemodialysis, who developed spontaneous rupture of the spleen during the course of her illness. The patient was managed conservatively with gradual regression of hematoma without further complications.
|How to cite this article:|
Nadri QJ, Alfurayh O. Spontaneous rupture of the spleen: A rare complication in a patient with lupus nephritis on hemodialysis.Saudi J Kidney Dis Transpl 2010;21:712-714
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Nadri QJ, Alfurayh O. Spontaneous rupture of the spleen: A rare complication in a patient with lupus nephritis on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Aug 19 ];21:712-714
Available from: http://www.sjkdt.org/text.asp?2010/21/4/712/64656
Rupture of the spleen is a potentially life threatening complication of abdominal injury with a frequency of occurrence of up to 40%. Spontaneous non-traumatic rupture is extremely rare and has been associated as an unusual event in patients with Systemic Lupus Erythematosus (SLE) and so far, five cases have been reported in the literature. ,,,, Spontaneous rupture in non-SLE hemodialysis (HD) patients has been described. We report a case of a patient with lupus nephritis receiving HD who developed spontaneous rupture of the spleen during the course of her illness. To our knowledge, this is the first reported case of such complication in a lupus patient on HD.
We report on a 40-year-old female patient diagnosed to have SLE with lupus nephritis class IV, seven years earlier. She had received treatment with steroids and cyclophosphamide earlier and was on maintenance therapy with cellcept. She was transferred to our institution from a local hospital with lupus flare and acute on chronic renal failure, for which she was on maintenance HD for one month prior to admission. The patient was confirmed to have active SLE clinically and serologically. Also, she was found to have multiple skin abscesses; pseudomonas were grown and she was treated with appropriate antibiotics. On the third day postadmission, the patient's hemoglobin dropped from baseline 90 g/L to 70 and then to 50 g/L within 24 hours. The patient remained hemodynamically stable, although there was an initial drop in blood pressure that responded to intravenous (i.v.) fluids and blood transfusion.
She did not have any hemoptysis, hematemesis or malena and her only complaint was left lumbar pain. Physical examination revealed soft abdomen, left upper quadrant abdominal tenderness and palpable spleen. Other examinations were unremarkable. Hemolytic workup was negative. Coagulation profile and platelet count were within normal limits. Antiphospholipid antibodies were also negative. Intraabdominal bleeding was suspected. A computerized tomography (CT) scan of the abdomen showed a 12.3 Χ 5.3 cm heterogeneous splenic subcapsular mass, associated with minimal stranding of the surrounding perisplenic fat suggestive of a splenic hematoma [Figure 1]. The patient was managed conservatively after surgical consultation. There was no further drop in hemoglobin and repeat CT scan ten days later showed no change in the size of the subcapsular splenic hematoma, which appeared less in density [Figure 2]. The patient recovered from acute renal failure and dialysis was discontinued. Follow-up CT scan after one year revealed interval regression of the splenic hematoma [Figure 3].
Spontaneous non-traumatic rupture of the spleen has been described in varieties of medical and surgical conditions such as malignancy, mostly lymphoproliferative disorders; Hodgkin's and Non-Hodgkins lymphomas; amyloidosis; infections such as infectious mononucleosis, malaria, brucellosis, meningococcal septicemia and streptococcal pneumonia; following procedures such as ERCP and colonoscopy; vasculitic diseases like rheumatoid arthritis and polyarteritis nodosa, and pancreatitis. SLE is a multisystem disease and splenomegaly and lymphadenopathy are well recognized features of this disease. While the majority of patients with SLE have mild splenomegaly, other splenic abnormalities can be associated with SLE including massive splenomegaly, splenic infarction and atrophy. So far, five cases of spontaneous splenic rupture in patients with SLE have been reported in the literature. ,,,, Several cases of non-traumatic rupture of the spleen have been described in non-SLE HD patients as well. They are secondary to tuberculosis,  pancreatitis,  post-colonoscopy,  splenic peliosis,  and unknown etiologies.  For reasons not known, spontaneous and traumatic rupture of the spleen has male predominance as described in literature.
Our patient (female) is a unique case of acute lupus nephritis requiring maintenance HD for a short duration that developed this complication. Rupture of the spleen has been classified into four grades.  Our patient falls in Grade-2 which comprises of sub-capsular hematoma > 3 cm diameter with intact capsule. Because of its rare occurrence, clinical and pathological factors that predispose the spleen to spontaneous rupture have not been identified. All postulated mechanisms such as coagulation disorders as well as antiphospholipid antibody syndrome with thrombosis and infarction were absent in this case. Uremic milieu, hypertension and uremic coagulopathy are possible contributing factors.  The effect of erythropoietin has also been suggested. 
Our study patient exemplifies that splenic rupture may occur late in the course of SLE and while on maintenance HD for a short duration. This is in contrast to previous reported cases of rupture, early in the course of SLE. Knowledge of this rare complication should lead to a high index of suspicion for accurate diagnosis and appropriate therapy.
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