Introduction
Splenic rupture is a rare life-threatening condition. Most cases of are secondary to trauma. However spontaneous rupture of the spleen (SRS) has been reported which in most cases are associated with infection or neoplasm. Previous cases of SRS have been reported with warfarin but none associated with Direct Oral Anticoagulation (DOAC). We present a case of SRS on apixaban for Atrial Fibrillation 2 days prior.

Case report
A 62-year-old lady presented to the ED with one-day history of dizziness, vomiting and feeling weak. ECG showed Atrial Fibrillation. Background history of hypothyroidism, hypertension, dyslipidemia and tonsillectomy. Known smoker and family history of MI. Four days ago, she presented to ED with gastroenteritis and new onset atrial fibrillation. Within the first 24 hours after admission, she developed worsening nausea, repeated ECG showed T wave inversion and rise in troponin. She then referred to the Cardiology team where she underwent PCI to RCA for 70-90% stenosis and discharged on Apixaban and Plavix. Two days later she represented to the ED pale and hypotensive. On examination GCS was 15/15, BP: 70/50, PR: 80 bpm. Systemic examination was unremarkable. The abdomen was soft and non-tender. Her hemoglobin came back at 8.7 g/dl which had dropped from 12g/dl in 2 days.

CT-Abdomen showed a large splenic hematoma and thickening of the inferior wall of the stomach. The Surgical team was informed and she was then taken for an emergency laparotomy with Splenectomy and Partial gastrectomy. She became septic post-operative; however, she responded well to antibiotics and was discharged on the day 18. The Apixaban was stopped and was discharged on lifelong prophylactic oral antibiotics.

Discussion
Spontaneous rupture of the spleen is a rare condition. There is often an underlying pathology such as an infectious disease (especially Epstein-Barr virus, hepatitis, salmonella, malaria), a neoplastic disease or connective tissue disease¹. Rokitansky first published a case of spontaneous rupture of the spleen in 1861, while in 1874, Atkinson first described the rupture of an apparently normal spleen ². Orloffn and Peskin³ identified four-step criteria for the diagnosis of spontaneous rupture consisting of: no trauma history, no perisplenic adhesions that may support previous trauma, no disease affecting the spleen, and presence of a normal spleen micro-and macroscopically. Crate and Payne added a fifth criterion in 1999 as lack of viral infections related to the spleen, especially no elevation in viral antibody titrations in the acute phase and incubation period. In this case, no history of trauma was reported and negative viral screening with normal microscopic and macroscopic examination of the spleen, hence our patient fit the criteria⁴.

This case demonstrates the importance of prompt recognition of a spontaneous splenic rupture in a patient on anticoagulation with DOAC. Consideration of this diagnosis should be entertained in any patient with abdominal pain or sudden drop in their hemoglobin who is on anticoagulation, even if there is no history of trauma. When there is suspicion of splenic rupture, ultrasound should be performed which may mostly comment on free fluid in the abdomen; however, multidetector CT is the first investigation of choice for diagnosing and staging of the splenic rupture and in deciding surgery.

Conflict of Interest

No conflict of interest.

Correspondence

Dr. Ayman Ahmed, University Hospital Galway, Ireland
E: [email protected] 
T: 00353858306704

References

1. Lacy E. Lowry and Jonathan A. Goldner: Spontaneous splenic rupture associated with apixaban: a case report, Journal of Medical Case Reports2016, DOI:10.1186/s13256-016-1012-6.
2. Gedik E, Girgin S, Aldemir M, Keles C, Tuncer MC, Aktas A. Non-traumatic splenic rupture: report of seven cases and review of the literature. World J Gastroenterol2008; 14:6711-6.
3. Orloff MJ, PeskinGW:Spontaneousrupture of normal spleen.IntAbs Surg1958;106:1–11.
4. Crate ID, Payne MJ. Is the diagnosis of spontaneous rupture of a normal spleen valid. J R Army Med Corps 1991; 137: 50-1.

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