E30 | VNITŘNÍ LÉKAŘSTVÍ / Vnitř Lék 2022;68(2):E29-E31 / www.casopisvnitrnilekarstvi.cz KAZUISTIKY Rare cause of spontaneous spleen bleeding: a case report and literature review the internal clinic for substitutional treatment and differential diagnosis. Due to persisting abdominal pain with negative X-ray of abdomen, contrast-enhanced CT examination was performed. CT showed a hemoperitoneum, hematoma in the spleen with active arterial bleeding (Figures No.1 and 2). The patient has repeatedly denied recent injury or trauma. Subsequently, she was moved to the surgical department and referred to acute surgical exploration. Laparotomy verified a hemoperitoneumwith approximately 500ml of blood and coagulum, with a 5cmhematoma of the spleen with superficial rupture and leakage of blood. A splenectomy was performed. During awakening from anaesthesia, the patient had an episode of hemoptysis. In the context of this information, we began to search the pathological conditions. She made a good recovery without any other complications. We performed a complex differential diagnosis, examination of blood, urine (with the finding of erythrocyturia), and autoantibodies. Hemato-oncological malignancies and inflectional diseases like EBV, CMV were excluded. Definitive histology has shown the picture of necrotising eosinophilic granulomatosis arteritis, which may correspond with a diagnosis of Churg-Strauss syndrome (Figures No.3 and 4). Patient was immediately referred to rheumatological examination. Discussion Atraumatic rupture of the spleen is an extremely rare condition, with an estimated prevalence of 0,1-0,5 %, twice more common in men (3). Risk factors include splenomegaly, hemato-oncological diseases, and infections, such as malaria or infectious mononucleosis (4). Splenic ruptures are extremely rarely described in autoimmune diseases, such as Wegener granulomatosis, lupus erythematosus, and polyarteritis nodosa (5). There has been no reported case of spontaneous splenic rupture as a first manifestation of Churg- Strauss syndrome so far. Of course, the possibility of an injury that the patient is not aware of must also be taken into account. Churg - Strauss syndrome (also known as eosinophilic granulomatosis with polyangiitis) is a very sporadic condition presented as disseminated necrotizing vasculitis and extravascular granulomas (6). This syndrome typically occurs in patients with preexisting asthma and eosinophilia Fig. 3, 4. Fibroid necrosis of medium large vessel (left, HE 200X) and hemoragic infarction of spleen due to necrotizing vasculitis (right, HE 40x) Fig. 1, 2. Active arterial bleeding in spleen (contrast enhanced CT, arterial phase)
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