Red-flag Syncope: Spontaneous Splenic Rupture

Presentation
After fainting in the lavatory, a healthy 59-year-old woman was taken to the hospital, where she would ultimately receive an unexpected diagnosis. On admission, she reported that she had been experiencing epigastric pain radiating to the left shoulder for several hours.

Assessment
The patient’s physical examination was remarkable for pallor, blood pressure of 86/45 mm Hg that later increased to 100/60 mm Hg, and epigastric tenderness. An electrocardiogram, chest x-ray, and abdominal x-ray were each normal. Laboratory tests showed that her hemoglobin was 9.5 g/dL, and her neutrophil count was 14.5 × 109 cells/L.

A rectal examination and gastroscopy were unremarkable except for a known diaphragmatic hernia, which was treated with pantoprazole. The patient’s hemoglobin dropped to 6.6 g/dL over 14 hours, and contrast computed tomography revealed free fluid in the abdomen, a large hematoma around the spleen, and active arterial bleeding (Figure). She had no history of trauma. Total splenectomy was immediately performed.

Diagnosis
While the patient’s spleen was normal in size (144 g) and results from histology and immunostaining were normal, it was ruptured and a massive subcapsular hematoma was evident. Few causes of syncope are more immediately life-threatening—and more difficult to diagnose—than spontaneous occult acute arterial bleeding in a previously healthy patient. Her low initial hematocrit (< 30%) and persistently low blood pressure (≤ 100 mm Hg) correctly stratified this patient’s syncope as high risk.(1) Although not specific, the presence of neutrophilia can be regarded here as a marker for the severity of bleeding.(2)

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–Ami Schattner, MD, Adi Meital, MD, Eliezer Mavor, MD

This article originally appeared in the June 2014 issue of The American Journal of Medicine.