key: cord-1049783-ibk0y1he
authors: Shaukat, Irfan; Khan, Raisa; Diwakar, Lavanya; Kemp, Timothy; Bodasing, Neena
title: Atraumatic splenic rupture due to covid − 19 infection
date: 2020-09-25
journal: Clin Infect Pract
DOI: 10.1016/j.clinpr.2020.100042
sha: 6eddd082ed542ca236edb318a115635aeffb735c
doc_id: 1049783
cord_uid: ibk0y1he

BACKGROUND: Covid-19 is a novel disease caused by the severe acute respiratory corona virus (SARS-CoV2). We discuss a gentleman who presented with an atraumatic rupture of the spleen secondary to this infection. BRIEF SUMMARY OF PRESENTATION. A 57-year-old service engineer was brought into the emergency department after having collapsed at home. RT-PCR was positive for Covid-19 infection. CT scan showed evidence of haemoperitoneum and splenic rupture. He underwent splenic artery embolisation and required ventilatory and circulatory support on ITU. He made a full recovery and was discharged home 3 weeks later. DISCUSSION AND RELEVANCE. Atraumatic splenic rupture is a rare, potentially fatal condition which has been described as a complication of haematological and non-haematological malignancies, inflammatory disorders and infections. There is emerging evidence to suggest that covid-19 has a direct destructive impact on the spleen, causing lymphoid follicle attrition and nodular atrophy in addition to microvascular thrombosis and necrosis. This is the first report of atraumatic splenic rupture secondary to covid-19 infection, to our knowledge.

Background: Covid-19 is a novel disease caused by the severe acute respiratory corona virus (SARS-CoV2). We discuss a gentleman who presented with an atraumatic rupture of the spleen secondary to this infection.

Brief summary of presentation: A 57-year-old service engineer was brought into the emergency department after having collapsed at home. RT-PCR was positive for Covid-19 infection. CT scan showed evidence of haemoperitoneum and splenic rupture. He underwent splenic artery embolisation and required ventilatory and circulatory support on ITU. He made a full recovery and was discharged home 3 weeks later.

Discussion and relevance: Atraumatic splenic rupture is a rare, potentially fatal condition which has been described as a complication of haematological and non-haematological malignancies, inflammatory disorders and infections. There is emerging evidence to suggest that covid-19 has a direct destructive impact on the spleen, causing lymphoid follicle attrition and nodular atrophy in addition to microvascular thrombosis and necrosis. This is the first report of atraumatic splenic rupture secondary to covid-19 infection, to our knowledge. Covid-19 is a novel disease caused by the severe acute respiratory corona virus (SARS-CoV2), which has been declared a pandemic by the World Health Organisation (WHO) on the 11th of March 2020 1 An ongoing observational study of inpatients in the UK has revealed that individuals with covid-19 present mainly with either respiratory, enteric or systemic symptoms 2 . We discuss a middle aged gentleman who had an unusual presentation of covid-19 infection.

A 57-year-old service engineer was brought in by ambulance having collapsed at home. He was feeling unwell for 10 days prior to admission with a dry cough, diarrhoea and reduced appetite. There was no history of trauma. He was a smoker with a 44 pack year history.

At arrival in the Accident and Emergency department, he looked pale and clammy. He was alert but confused and complained of abdominal pain. He was short of breath at rest, with a respiratory rate of 28 per minute. On examination, there was no rash or lymphadenopathy. There were fine crackles heard in both lung bases. Abdominal examination confirmed a tender, rigid abdomen. His blood pressure at admission was 86/56, heart rate was 126 bpm, saturation 98% on 60% oxygen, and the temperature was 37.2. ECG showed tachycardia but no ischemic changes. Urine dipstick was normal.

Past medical history included moderate obstructive sleep apnoea, chronic lower back pain following L4/L5 discectomy, chronic bronchitis, excision of left lower lobe of the lung following trauma 20 years previously and radical prostatectomy for cancer (10 years ago). He was generally fit and well.

There was no recent travel history of note. He denied any high risk sexual or social behaviours. He did not have any personal or family history of leukaemia, lymphoma, autoimmune diseases or coagulopathies. Table 1 . Blood gas analysis showed evidence of metabolic acidosis (see Table 1 ).

An emergency CT scan of the chest and abdomen was carried out which showed fluid in both subdiaphragmatic spaces, paracolic gutters and pelvis suggestive of a haemoperitoneum. The spleen was normal sized, heterogenous in texture, with evidence of extracapsular rupture. The chest images showed peripheral ground glass consolidation in bases of both lungs, consistent with covid19 infection (Fig 1 and 2) .

The other imaged abdomino-pelvic viscera were reported as normal with no significant lymphadenopathy in the imaged areas. He was started on vigorous fluid resuscitation and was transferred to critical care for ventilatory and circulatory support. He was transfused with packed red cells, FFP and given IV Tranexamic acid. He underwent a splenic artery embolisation procedure to stop the haemorrhage, following which he stabilised. He deteriorated in ITU whilst on high flow oxygen and was, therefore, ventilated on Day 2 of admission. Renal replacement therapy was not needed and Inotropic support continued until Day 7. On day 8, a tracheostomy was performed because of agitation and failed sedation hold. He was weaned off the ventilator on Day 13. On Day 14, he developed urosepsis and Klebsiella spp was isolated from urine. This was treated with IV co-amoxiclav for 7 days.

He steadily improved in hospital after this with a complete resolution of acute kidney injury and was discharged home on Day 24.

Atraumatic splenic rupture is a rare, potentially fatal condition which has been described as a complication of haematological and non-haematological malignancies, inflammatory disorders and infections 4 . Viral infections implicated include EBV, HIV, CMV and Dengue. The condition carries a J o u r n a l P r e -p r o o f high mortality rate and therefore, an early diagnosis is necessary for good outcomes. Splenectomy is commonly performed, although spleen preserving procedures such as arterial embolisation are considered to avoid unnecessary surgery where appropriate 5 .

There is emerging evidence to suggest that covid-19 has a direct impact on the spleen and lymph nodes inducing severe tissue damage including lymphoid follicle depletion, splenic nodule atrophy, histiocytic hyperplasia and lymphocyte reduction 6 . In addition, covid-19 is reported to induce microvascular thrombosis and necrosis affecting the spleen 7 . Just as with our patient, peak organ involvement in covid-19 occurs around day 10 8 . Although we are unable to provide direct histological evidence, the trajectory of illness and lack of any other underlying pathology are highly suggestive of splenic rupture in this case being secondary to covid-19 infection. Figure 1 

WHO Virtual press conference on COVID-19

UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol

Systematic review of atraumatic splenic rupture

Use of splenic artery embolization as an adjunct to nonsurgical management of blunt splenic injury

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) directly decimates human spleens and lymph nodes. medRxiv

Diagnosis, Prevention, and Treatment of Thromboembolic Complications in COVID-19: Report of the National Institute for Public Health of the Netherlands

Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia