CLINICAL COMMUNICATION TO THE EDITOR
Spontaneous Splenic Rupture in an Intravenous Drug Abuser To the Editor: Atraumatic splenic rupture is rare and can be a sequel of infections, hematological or metastatic malignancy, and vascular disorders. We report a case of atraumatic splenic rupture in an illicit-drug user who presented with hemorrhagic shock after intravenous cocaine and heroin injection.
CASE PRESENTATION A 39-year-old man with history of intravenous illicit-drug abuse, alcohol abuse, and recurrent episodes of deep vein thrombosis presented to the Emergency Department with left shoulder and abdominal pain without any history of trauma. He reported self-injection of a bolus mix of heroin and cocaine into his groin on the day of admission. Initial examination was unremarkable, and the radiographs of the chest and left shoulder and blood tests were normal. A few hours later he fainted while getting up from bed. He became hypotensive, with a drop in hemoglobin level of 30 g/L (from 135 g/L at admission) without any evidence of overt bleeding. A bedside echocardiography was normal. An ultrasonography of the abdomen revealed a splenic length of 12.5 cm, with a hypoechogenic texture and evidence of ascites in the upper abdomen and pelvis. An emergency esophagogastroduodenoscopy after 3 units of packed red blood cell transfusion showed only mild gastritis and duodenitis. An urgent computed tomographic scan of the abdomen revealed a large intrasplenic and perisplenic hematoma (Figure, arrow) and hemoperitonium. An emergency exploratory laparotomy revealed a large splenic hematoma with some active bleeding from the splenic parenchyma. Splenectomy was performed, with removal of about 3000 mL of blood from peritoneal cavity. No other intra-abdominal abnormality was noticed. Funding: None. Conflict of Interest: None. Authorship: All authors participated in the preparation of the manuscript and approved the final version of the manuscript. Requests for reprints should be addressed to Joseph M. Pappachan, MD, MRCP, Department of Endocrinology & Metabolism, University Hospital North Staffordshire, Stoke on Trent, ST4 6QG, UK. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
Histology of the excised spleen did not reveal any organic pathology. The patient made a full and uneventful recovery and was transferred to an inpatient de-addiction center a week later.
DISCUSSION The spleen has a reserve of about 500 mL of blood and receives roughly 5% of cardiac output.1 Due to its structure and vascularity, when injured, it has the potential for uncontained and extensive intraperitoneal hemorrhage. The spleen is the most commonly damaged organ in blunt abdominal trauma, and patients often present with pain and hemorrhagic shock. Atraumatic splenic rupture is rare and often referred to as a pathological rupture. In comparison, various yet relatively rare causes of atraumatic splenic rupture include both viral and bacterial infections such as infectious mononucleosis and streptococcus pneumonia, primary hematological malignancy, metastatic malignancies, and vascular disorders.2 Only 7% of cases of atraumatic splenic rupture were found to be idiopathic in a systematic review of atraumatic splenic rupture that included a total of 845 patients.2 Timely diagnosis of atraumatic splenic rupture is of paramount importance because the reported mortality rate is as high as 12.2%. Intravenous drug abuse as a direct cause of splenic rupture has not been reported previously.
Figure Computed tomographic scan of the abdomen showing hematoma of the spleen (white arrow) and hemoperitoneum.
e8 Vascular complications of intravenous drug abuse are well known. Both cardiovascular and cerebrovascular complications are common with cocaine and heroin. These drugs stimulate the sympathetic nervous system by inhibition of catecholamine reuptake at the nerve terminals, stimulation of the central sympathetic outflow, and the increased sensitization of adrenergic nerve endings to norepinephrine.3 Acute vascular events such as stroke and myocardial infarction are not uncommon in illicit drug users. Relatively high prevalence of both hemorrhagic and ischemic strokes have been described among drug addicts.4 Sudden sympathetic surge that results from the intravenous injection of cocaine and heroin can cause vascular rupture and hemorrhage. High blood flow and poor connective tissue support of splenic vasculature make it prone for easy bleeding. Illicit drug abuse on the day of initial evaluation would have precipitated splenic hemorrhage in this patient.
The American Journal of Medicine, Vol 127, No 3, March 2014 Ffion Carlin, MBChB Adrian B. Walker, DM Joseph M. Pappachan, MD Department of Endocrinology, Diabetes & Metabolism University Hospital of North Staffordshire Stoke-on-Trent, UK
http://dx.doi.org/10.1016/j.amjmed.2013.09.035
References 1. Karlo CA, Stolzmann P, Do RK, Alkadh H. Computed tomography of the spleen: how to interpret the hypodense lesion. Insights Imaging. 2013;4:65-76. 2. Renzulli P, Hostettler A, Schoepfer AM, Gloor B, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg. 2009;96: 1114-1121. 3. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122:2558-2569. 4. Cami J, Farre M. Drug addiction. N Engl J Med. 2003;349:975-986.
Spontaneous Splenic Rupture in an Intravenous Drug Abuser To the Editor: Atraumatic splenic rupture is rare and can be a sequel of infections, hematological or metastatic malignancy, and vascular disorders. We report a case of atraumatic splenic rupture in an illicit-drug user who presented with hemorrhagic shock after intravenous cocaine and heroin injection.
CASE PRESENTATION A 39-year-old man with history of intravenous illicit-drug abuse, alcohol abuse, and recurrent episodes of deep vein thrombosis presented to the Emergency Department with left shoulder and abdominal pain without any history of trauma. He reported self-injection of a bolus mix of heroin and cocaine into his groin on the day of admission. Initial examination was unremarkable, and the radiographs of the chest and left shoulder and blood tests were normal. A few hours later he fainted while getting up from bed. He became hypotensive, with a drop in hemoglobin level of 30 g/L (from 135 g/L at admission) without any evidence of overt bleeding. A bedside echocardiography was normal. An ultrasonography of the abdomen revealed a splenic length of 12.5 cm, with a hypoechogenic texture and evidence of ascites in the upper abdomen and pelvis. An emergency esophagogastroduodenoscopy after 3 units of packed red blood cell transfusion showed only mild gastritis and duodenitis. An urgent computed tomographic scan of the abdomen revealed a large intrasplenic and perisplenic hematoma (Figure, arrow) and hemoperitonium. An emergency exploratory laparotomy revealed a large splenic hematoma with some active bleeding from the splenic parenchyma. Splenectomy was performed, with removal of about 3000 mL of blood from peritoneal cavity. No other intra-abdominal abnormality was noticed. Funding: None. Conflict of Interest: None. Authorship: All authors participated in the preparation of the manuscript and approved the final version of the manuscript. Requests for reprints should be addressed to Joseph M. Pappachan, MD, MRCP, Department of Endocrinology & Metabolism, University Hospital North Staffordshire, Stoke on Trent, ST4 6QG, UK. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
Histology of the excised spleen did not reveal any organic pathology. The patient made a full and uneventful recovery and was transferred to an inpatient de-addiction center a week later.
DISCUSSION The spleen has a reserve of about 500 mL of blood and receives roughly 5% of cardiac output.1 Due to its structure and vascularity, when injured, it has the potential for uncontained and extensive intraperitoneal hemorrhage. The spleen is the most commonly damaged organ in blunt abdominal trauma, and patients often present with pain and hemorrhagic shock. Atraumatic splenic rupture is rare and often referred to as a pathological rupture. In comparison, various yet relatively rare causes of atraumatic splenic rupture include both viral and bacterial infections such as infectious mononucleosis and streptococcus pneumonia, primary hematological malignancy, metastatic malignancies, and vascular disorders.2 Only 7% of cases of atraumatic splenic rupture were found to be idiopathic in a systematic review of atraumatic splenic rupture that included a total of 845 patients.2 Timely diagnosis of atraumatic splenic rupture is of paramount importance because the reported mortality rate is as high as 12.2%. Intravenous drug abuse as a direct cause of splenic rupture has not been reported previously.
Figure Computed tomographic scan of the abdomen showing hematoma of the spleen (white arrow) and hemoperitoneum.
e8 Vascular complications of intravenous drug abuse are well known. Both cardiovascular and cerebrovascular complications are common with cocaine and heroin. These drugs stimulate the sympathetic nervous system by inhibition of catecholamine reuptake at the nerve terminals, stimulation of the central sympathetic outflow, and the increased sensitization of adrenergic nerve endings to norepinephrine.3 Acute vascular events such as stroke and myocardial infarction are not uncommon in illicit drug users. Relatively high prevalence of both hemorrhagic and ischemic strokes have been described among drug addicts.4 Sudden sympathetic surge that results from the intravenous injection of cocaine and heroin can cause vascular rupture and hemorrhage. High blood flow and poor connective tissue support of splenic vasculature make it prone for easy bleeding. Illicit drug abuse on the day of initial evaluation would have precipitated splenic hemorrhage in this patient.
The American Journal of Medicine, Vol 127, No 3, March 2014 Ffion Carlin, MBChB Adrian B. Walker, DM Joseph M. Pappachan, MD Department of Endocrinology, Diabetes & Metabolism University Hospital of North Staffordshire Stoke-on-Trent, UK
http://dx.doi.org/10.1016/j.amjmed.2013.09.035
References 1. Karlo CA, Stolzmann P, Do RK, Alkadh H. Computed tomography of the spleen: how to interpret the hypodense lesion. Insights Imaging. 2013;4:65-76. 2. Renzulli P, Hostettler A, Schoepfer AM, Gloor B, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg. 2009;96: 1114-1121. 3. Schwartz BG, Rezkalla S, Kloner RA. Cardiovascular effects of cocaine. Circulation. 2010;122:2558-2569. 4. Cami J, Farre M. Drug addiction. N Engl J Med. 2003;349:975-986.
