Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
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

Correspondence Address:
Quaid J Nadri
King Faisal Specialist Hospital and Research Center, Department of Medicine, MBC # 46, P.O. Box 3354, Riyadh 11211
Saudi Arabia

Abstract

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


How to cite this URL:
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


Full Text

 Introduction



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. [1],[2],[3],[4],[5] 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.

 Case History



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].

 Discussion



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. [1],[2],[3],[4],[5] Several cases of non-traumatic rupture of the spleen have been described in non-SLE HD patients as well. They are secondary to tuberculosis, [6] pancreatitis, [7] post-colonoscopy, [8] splenic pelio­sis, [9] and unknown etiologies. [10] 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. [11] 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. [12] The effect of erythropoietin has also been suggested. [9]

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.

References

1Zimmerman-Gorska I, Bielaka K. Splenic rup­ture in the course of SLE. Pol Tyg Lek 1971; 26:1991-2.
2Krauser R. Spontaneous rupture of the spleen in the systemic lupus erythematosus. JAMA 1976;236:1149.
3Cheng-Chung W, Lan J, Liu T. Systemic Lupus erythematosus with spontaneous rupture of the spleen. Formosan Med Assoc 1985; 84:1186-990.
4Tolaymat A. Al-Mousily F, Haafiz AB, Lammert N, Afshari S, Spontaneous rupture of the spleen in a patient with systemic lupus erythe­matosus. J Rheumatol 1995;22:2344-5.
5Karassa FB, Isenberg DA. Spontaneous rupture of the spleen: an unusual complication of systemic lupus erythematosus. Lupus 2001;10: 876-8.
6Ram R, Swarnalatha G, Prasad N, Murty KV Pathological rupture of spleen in a hemo­dialysis patient due to tuberculosis. Nephrol Dial Transplant 2006;21(10):2994-5
7Katsanos KH, Theodorou J, Katopodis KP, Siamopoulos KC. Spontaneous splenic rupture complicating pancreatitis in a chronic hemo­dialysis patient. Clin Nephrol 2004;61(6):448-9.
8Zerbi S, Crippa S, Di Bella C, Nobili P, Bonforte G, Scanziani R. Splenic rupture follo­wing colonoscopy in a hemodialysis patient. Int J Artif Organs 2006;29(3):335-6.
9Hakoda S, Shinya H, Shunichiro S. Sponta­neous splenic rupture caused by splenic peliosis of a hemodialysis patient with chronic renal failure receiving erythropoietin. Am J Emerg Med 2008;26:109.
10Kim HJ, Lee GW, Park DJ, Lee JD. Spon­taneous splenic rupture in a hemodialysis patient. Yonsei Med J 2005;46(3):435-8.
11Gorg C, Colle J, Gorg K, et al. Spontaneous rupture of the spleen: ultrasound patterns, diagnosis and follow-up. Br J Radiol 2003;76: 704-11.
12Aldemir M, Suner A, Kidir V. Spontaneous rupture of the spleen in a hemodialysis patient. Eur J Gen Med 2004;1(3):51-4.