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Background: Spontaneous splenic rupture is often life threatening due to delay in diagnosis and treatment. Abdominal pain, Kehr's sign, nausea, bloating, altered consciousness, and intestinal obstruction may be present. In larger splenic lesions, signs of peritonitis and hypovolemic shock are present. Contrast-enhanced computed tomography is the election study. Diagnosis is confirmed by negative viral serology and normal spleen on gross and histopathologic inspection. The most frequent treatment in splenectomy. Clinic case: A 30-year-old male with no medical history presented with generalized abdominal pain accompanied by Kehr's sign. He is diagnosed with ruptured spleen by contrast-enhanced computed tomography and successfully treated with splenectomy. He was discharged 6 days after surgery. Conclusions: Spontaneous rupture of the spleen is uncommon, but with high morbidity and mortality. It must be a differential diagnosis in the face of abdominal and/or chest pain, and the corresponding imaging studies should be carried out if the patient's conditions allow it, or their search during an exploratory laparotomy.

Introducción: la ruptura esplénica espontánea frecuentemente es mortal debido a la demora en el diagnóstico y tratamiento. Se puede presentar dolor abdominal, signo de Kehr, náuseas, distensión abdominal, alteración de la consciencia y obstrucción intestinal. En lesiones esplénicas más grandes, se presentan signos de peritonitis y shock hipovolémico. El estudio de elección es la tomografía computarizada contrastada. El diagnóstico se confirma por serología viral negativa y bazo normal en la inspección macroscópica e histopatológica. El tratamiento más frecuente es la esplenectomía. Caso clínico: paciente hombre de 30 años de edad, sin antecedentes patológicos, con dolor abdominal generalizado, acompañado del signo de Kehr. Es diagnosticado con ruptura de bazo por tomografía computarizada contrastada y tratado exitosamente con esplenectomía. Se egresa a los 6 días postquirúrgicos. Conclusiones: la ruptura espontánea del bazo es poco común, pero con alta morbimortalidad. Debe ser un diagnóstico diferencial ante un dolor abdominal y/o torácico, y realizar los estudios de imagen correspondientes si las condiciones del paciente lo permiten o bien su búsqueda durante una laparotomía exploratoria.

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Resumen La rotura esplénica es una complicación rara pero potencialmente fatal de la mononucleosis infecciosa. Presentamos el caso de una mujer de 18 años que consultó por dolor abdominal de siete días de evolución, asociado a fiebre y pérdida de conciencia brusca y transitoria. En el hemograma presentaba una anemia y linfocitosis. Se realizó una tomografía computada de abdomen y pelvis que mostró un extenso hemoperitoneo, con el bazo rodeado por un hematoma, y numerosas adenopatías cervicales, mesentéricas e inguinales. Se efectuó una laparoscopía que demostró abundante hemoperitoneo con coágulos a lo largo de la gotera parietocólica izquierda. El bazo estaba completamente decapsulado y rodeado por una colección hemática con sangrado en napa. Se realizó una esplenectomía total sin complicaciones. El estudio histopatológico esplénico mostró una atenuación de la pulpa blanca y expansión de la pulpa roja con áreas de hemorragia y necrosis. La IgM anti-cápside para virus de Epstein Barr fue positiva. La paciente evolucionó de manera favorable.

Abstract Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. We report the case of an 18-year-old woman, who presented a 7-day history of abdominal pain, sudden temporary loss of consciousness and fever. Admission blood tests showed anemia, and lymphocytosis. Computed tomography of the abdomen and pelvis demonstrated extensive hemoperitoneum and numerous cervical, mesenteric and inguinal enlarged lymph nodes. Laparoscopy was performed and abundant hemoperitoneum with blood clots along the left parietocolic gutter were observed. The spleen was completely decapsulated and surrounded by a hematoma and the subcapsular tissue was bleeding. Total splenectomy was performed without complications. Splenic histology demonstrated white pulp attenuation and expansion of the red pulp with focal hemorrhage and necrosis. IgM anti-viral capsid antigen of Epstein Barr virus was positive. The patient had a satisfactory recovery.

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BACKGROUND: Splenomegaly is one of the most common features of malaria. However, spontaneous splenic rupture, although unusual, represents a severe complication often leading to death. It is mostly seen in acute infection and primary attack, and it is most commonly associated with Plasmodium vivax. Here, a case of spontaneous splenic rupture diagnosed with a portable ultrasound apparatus shortly after starting treatment and with recurrent parasitaemia after splenectomy, is reported. CASE DESCRIPTION: In November 2015, a 45-year-old Brazilian man presented to the hospital in Manaus with fever, headache and myalgia. He was diagnosed with P. vivax malaria and, after a normal G6PD test, he started treatment with chloroquine and primaquine and was discharged. Two days later, he went back to the hospital with abdominal pain, dyspnea, dry cough, pallor, oliguria and fever. Using a portable ultrasound, he was diagnosed of rupture of the spleen, which was removed by emergency surgery. After this episode, he suffered two more malaria episodes with high parasitaemia at approximately 2-month intervals. DNA from different portions of the spleen was extracted and a qualitative PCR was performed to detect P. vivax. CONCLUSIONS: The splenic rupture suffered by this patient occurred 2 days after starting the treatment. Having a portable ultrasound apparatus may have saved the patient's life, as it revealed a haemorrhage needing an urgent surgery. Parasites were detected by PCR in the extracted spleen. This patient suffered two more vivax malaria diagnosed episodes in spite of receiving and completing treatment with chloroquine and primaquine for each clinical attack. Splenic rupture during acute malaria is uncommon, but it is likely underdiagnosed and underreported, because the lack of means and equipment hinders diagnostic confirmation, especially in endemic areas.

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A ruptura esplênica é uma complicação possível da malária. É importante pela dificuldade diagnóstica, pois um elevado índice de suspeição é necessário para um diagnóstico atempado. Pode condicionar uma hemorragia intraperitoneal e deve ser considerada no diagnóstico diferencial de quadros de dor abdominal, hipotensão e diminuição do hematócrito. Os autores descrevem o caso de um homem de 59 anos, com ruptura esplênica secundária à malária por Plasmodium falciparum, tendo realizado esplenectomia urgente. Com a apresentação do caso, os autores pretendem chamar a atenção para a necessidade de incluir esta afecção no diagnóstico diferencial dos doentes com malária e hipotensão refractária.

Splenic rupture is a possible complication of malaria. Due to its difficult diagnosis, it is important, because a high level of suspicion is needed for a timely diagnosis. It results in intraperitoneal bleeding and should be considered in the differential diagnosis of abdominal pain, hypotension and low hematocrit. The authors report the case of a 59-year old man with splenic rupture secondary to malarial infection by Plasmodium Falciparum, who was treated with urgent splenectomy. This case is presented to remind the clinicians of include this entity in the differential diagnosis of patients with malaria and refractory hypotension.

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We describe the case of a 67-year-old female patient with a history of femoral-distal bypass graft with sudden onset of unremitting leg pain, who had recently received tissue plasminogen activator (t-PA). The patient reported non-compliance with her warfarin regimen. Angiography revealed occlusion of the bypass graft. Infusion of t-PA was performed via a right femoral artery approach. On hospital day two, the patient developed nausea and abdominal pain with associated hypotension. A CT scan showed a massive intra-abdominal and pelvic free fluid consistent with blood. The spleen was enlarged and fluid noted around the liver. At laparotomy, a grade III splenic laceration at the hilum was identified and a splenectomy performed. The patient recovered completely. Although rare, spontaneous splenic rupture should be considered in the differential diagnosis of patients undergoing thrombolytic therapy who develop signs of hemodynamic instability.

Descrevemos o caso de uma paciente de 67 anos com histórico de enxerto fêmoro-distal com início súbito de dor repetitiva em membro inferior e que havia recebido ativador de plasminogênio tecidual (AP-t) recentemente. A paciente relatou não adesão ao seu tratamento com warfarina. A angiografia revelou oclusão do enxerto. O AP-t foi administrado via artéria femoral direita. No segundo dia de hospitalização, a paciente apresentou náuseas e dor abdominal com hipotensão associada. Uma tomografia computadorizada revelou a existência de um fluido pélvico e intra-abdominal livre em grande quantidade, com suspeita de que fosse sangue. O baço estava crescido, e o fluido foi observado em torno do fígado. A laparotomia identificou uma laceração grau III no hilo esplênico, e uma esplenectomia foi realizada. A paciente teve recuperação completa. Embora rara, a ruptura esplênica espontânea deve ser considerada no diagnóstico diferencial de pacientes submetidos a terapia trombolítica que apresentem sinais de instabilidade hemodinâmica.

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Dengue is a febrile illness caused by Flavivírus and mainly transmitted by the mosquito Aedes aegypiti which have been a serious epidemic in Rio de Janeiro. In most of cases it was a self limited disease. We report two cases of a serious and rare complication of this viral infection.

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Dengue is a febrile illness caused by Flavivírus and mainly transmitted by the mosquito Aedes aegypiti which have been a serious epidemic in Rio de Janeiro. In most of cases it was a self limited disease. We report two cases of a serious and rare complication of this viral infection.

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O abscesso esplênico é uma condição rara, de difícil diagnóstico e com alta mortalidade. O diagnóstico deve ser considerado naqueles pacientes com febre, dor abdominal e condições de imunossupressão. A esplenectomia tem sido o tratamento de escolha, com alta morbimortalidade. A abordagem percutânea pode ser uma boa alternativa.

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Splenic rupture is frequently produced due to traumatic mechanisms, being referred to as spontaneous or pathological when there is no history of trauma or there is an underlying splenic disease. Spontaneous splenic rupture due to amyloid deposits is a very uncommon cause of surgical acute abdomen. The patient in this case is a woman admitted with acute abdomen secondary to spontaneous splenic rupture, whose final diagnosis was primary amyloidosis.

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