Pathological rupture of malarial spleen.AJ Mokashi, RG Shirahatti, SK Prabhu, KR Vagholkar
Dept of Gastroenterological Surgical Services, TN Medical College, Bombay, Maharashtra.
Two cases of spontaneous rupture of malarial spleen are reported here. One of them was a male who was on chloroquine for an acute attack of malaria. While on therapy, he complained of pain in left hypochondrium followed by palpitations. The other patient was a female who was admitted for continuous dull aching pain and fever. In both the patients, exploratory laparotomy revealed an enlarged spleen with tear. Splenectomy was performed. Histopathological examination revealed dilated congested sinusoid with follicular atrophy, and RBCs with malarial parasites. The post-operative course was smooth in both patients.
Keywords: Adult, Case Report, Female, Human, Malaria, Vivax, pathology,Male, Middle Age, Rupture, Spontaneous, Splenectomy, Splenic Rupture, pathology,surgery,
The spleen plays an important role in areas where malaria is common, producing antibodies against the malarial parasite. The splenic involvement in malaria causing splenomegaly makes it more prone to complications such as rupture. Pathological or spontaneous rupture of the malarial spleen i.e. non-traumatic rupture is a rare complication as malarial spleen is tougher than the normal spleen. We report two cases of spontaneous rupture of the malarial spleen, treated by splenectomy.
A 26-year-old male was admitted with intermittent, high grade, fever with chills for five days. On examination he was febrile and anaemic. The spleen was palpable, 3 cm below the left costal margin. A provisional diagnosis of malaria was made which was confirmed on peripheral smear, which showed schizonts of Plasmodium vivax. Chloroquine was prescribed. On the third day, he suddenly developed pain in the left hypochondrium, which radiated to the back and the left shoulder. The pain became generalised and was associated with increasing pallor. He developed tachycardia with a pulse of 112/min and BP of 110/70mm of Hg. There was tenderness all over the abdomen, more so in the left hypochondrium, but there was no abdominal guarding or rigidity.
The bowel sounds were feeble. Abdominal paracentesis showed the presence of hemoperitoneum. Exploratory laparotomy revealed the presence of 2,000 mi of blood in the peritoneal cavity. The enlarged spleen (20 cm x 12 cm) with adhesions to the surrounding structures was congested with a tear on the anterior surface (3 cm x 0.5 cm) and with a subcapsular haematoma. Splenectomy was performed. He had a smooth post-operative recovery except for left basal pneumonia, which cleared rapidly with antibiotics and physiotherapy.
The spleen that was removed weighed 850 gm and measured 20 cm x 12 cm x 5 cm. On gross examination, it was dark grey in colour and had a capsular tear with subcapsular haematoma on the medial side. The microscopic examination showed thickening of the capsule with congestion and thrombosis. Few RBCs with malarial parasites were also seen on the Giemsa stain (See [Figure - 1])
A 58-year-old female was admitted with intermittent, high grade fever with chills for 6 days and dull aching, continuous pain in the lower abdomen more so on the right side for 2 days. She had occasional vomiting and had visited a malarial endemic area. She was febrile on examination and had a rapid pulse rate (124/min) with normal BP. On abdominal examination, she had guarding and tenderness in both the iliac fossae.
Bowel sounds were feeble and X-ray abdomen showed a ground glass appearance with dilated bowel loops. Exploratory laparotomy revealed about 200 gms of blood clots in the pelvis and an enlarged spleen, almost double its normal size, with a tear on the superior surface measuring 1.5 cm x 0.3 cm. There were adhesions with surrounding structures and the spleen was quite friable. Splenectomy was performed. She had a smooth recovery after surgery. The peripheral smear done in the post-operative period did not show any malarial parasites.
The splenic specimen weighed 280 gms. Gross examination showed “peeling off” of the capsule at a few places with blackish discolouration. The cut surface showed greyish brown discolouration without any evidence of infarction. Microscopy revealed features of congestive splenomegaly with atrophy of the lymphoid follicles, dilatation of the sinusoids and mononuclear cell infiltration. Parasitised RBCs showing P vivax was also seen with Giemsa stain.
Pathological rupture of the spleen occurs in malaria, kala-azar, infectious mononucleosis, viral hepatitis, typhoid, arnyloidosis and Gaucher's disease. Malaria is the most common cause followed by infectious mononucleosis,
The exact mechanism by which the spleen ruptures is not known. However, three mechanisms are thought to play a part in the process. (a) increase in intrasplenic tension due to cellular hyperplasia and engorgement; (b) compression by abdominal musculature during physiologic activities such as sneezing, coughing, defecation and sitting up or turning in bed and (c) vascular occlusion due to reticulo-endothelial hyperplasia causing thrombosis and infarction. This leads to interstitial and subcapsular haemorrhage and stripping of the capsule, which leads to further subcapsular haemorrhage. The distended capsule then finally gives way.
In short, a rapidly enlarging spleen with underlying vascular alterations predispose the spleen to rupture and a subcapsular haematoma usually precedes the rupture.
Lubitz  studied pathologic rupture of the spleen in acute Plasmodium vivax malaria and described the changes occurring in the spleen. The spleen usually weighs 400-500 gms and is soft in consistency, reddish in colour rather than slate grey. The tear occurs on any surface and is usually single measuring a few mm to 10 cm. Microscopic examination findings are diffuse hyperplasia with sinusoids showing subintimal and adventitial leukopoesis, dilated sinuses and thrombosis. Malarial parasites may not be seen in the spleen.
Splenectomy has been the treatment of choice in case of pathologic rupture of the spleen. But, due to the important role of spleen in the immune response to pneumococcal and malarial infections, conservative management is prescribed. In this non-operative conservative management, the patient is given blood transfusions to maintain his haemodynamic status and complete bed rest is advised. Repeated ultrasonography or CT scan is done to assess the healing. Healing of the ruptured spleen is usually complete in 2-3 week’s time.
[Figure - 1]