Sudden spleen rupture in a Plasmodium vivax-infected patient undergoing malaria treatment

Background Blunt abdominal trauma is the most common cause of splenic rupture. Non-traumatic rupture is rare and occurs in diseased spleen. The leading cause of non-traumatic splenic rupture is hematological malignancy, followed by infections, vascular, genetic and hematological disorders. However, in malaria endemic countries, the infection outnumbers hematological malignancies as a splenic rupture cause. Clinical Case and Diagnostic Methods A 45-year-old man from Manaus presented to the hospital with fever, headache and myalgia. He was diagnosed with Plasmodium vivax malaria and, after a normal qualitative G6PD test, treatment with Chloroquine and Primaquine was prescribed. The patient was discharged, but two days later, he went back to the hospital referring abdominal pain, dyspnea, dry cough, pallor, oliguria and fever. Results Physical examination showed tenderness in the left hypochondriac region, rebound tenderness and abdominal guarding. A blood analysis showed 5.53 g/dl of hemoglobin and 15.98% of hematocrit. Splenic rupture was suspected, being confirmed afterwards by an ultrasonography. Also, the patient received a blood transfusion for the anemia. An emergency splenectomy was performed with the spleen showing enlargement (17 x 14 x 7.5 cm) and a large subcapsular hematoma. Afterwards, DNA from different splenic portions was extracted from frozen cuts and a qualitative PCR test (Plasmodium vivax-MSP1(19)) was positive for the parasite. Conclusions Although splenomegaly is a frequent clinical feature of malaria, the incidence of spontaneous splenic rupture is uncommon (0-2%). Spontaneous rupture of the spleen in malaria is most frequently seen in acute infection, during the primary attack, and associated with P. vivax infection.