a b s t r a c t

Novel oral anticoagulants (NOACs) are increasingly popular. Spontaneous splenic rupture is rare and life- threatening, especially if it is not immediately recognized. Prior work has demonstrated an association with NOAC use and spontaneous splenic rupture in unusual clinical circumstances. We present the case of spontane- ous splenic hemorrhage in a largely healthy 57-year old female who was recently started on apixiban for a pro- voked PE. She had been discharged from an outside facility, and presented just hours after discharge to our emergency department in extremis: unconscious, pale, hypotensive, and tachycardic. Her abdomen on arrival was noted to be distended with positive fluid wave, and bedside ultrasound confirmed massive peritoneal fluid. Prompt diagnostic peritoneal aspirate confirmed hemoperitoneum, and a massive transfusion protocol was initiated. The patient’s Blood pressure and heart rate improved, and she was stabilized for imaging. Com- puted tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen. The patient was taken emergently to interventional radiology suite where splenic artery emboliza- tion was performed and an IVC filter was placed. She subsequently developed acute respiratory distress syn- drome and persistent low urine output with hypotension despite resuscitation, and was taken to the operating room for splenectomy and abdominal washout. She improved thereafter and was discharged 12 days later. prompt diagnosis and aggressive early resuscitation contributed to this patient’s outcome.

(C) 2019

Introduction

Novel oral anticoagulants (NOACs) are increasingly popular. Sponta- neous splenic rupture is rare and life-threatening, especially if it is not immediately recognized [1,2]. Organ-specific bleeding patterns among the NOACs include reduced associated intracranial hemorrhage and GI bleed risk relative to warfarin [3]. Splenic rupture is exceeding rare rel- ative to these other Bleeding complications. In almost all cases, splenic rupture is associated with an underlying pathologic process (atraumatic-Pathologic rupture) rather than atraumatic and idiopathic. Prior work has demonstrated an association with novel oral anticoagu- lant (NOAC) use and spontaneous splenic rupture in the case of precip- itant conditions [4,5] and in patients with severe underlying chronic disease [6,7]. While the case of splenic rupture in infectious mononucle- osis is well-known, more atypical associations with infections include babesiosis [4] and following IVIg treatment for parvovirus B19-related pure red cell aplasia [8]. In the case of an Ectopic pregnancy in the spleen [9], the underlying pathological mechanism is more clear. Among the earliest cases of spontaneous splenic rupture associated with a NOAC, Gonzva et al. described an acute presentation of shock in a 67-year old in France who ultimately did well after resuscitation, splenectomy,

* Corresponding author.

E-mail address: [email protected] (A. Janke).

and a Intensive care unit stay complicated by colonic ischemia requiring colectomy [10].

Case description

We present a case of spontaneous splenic hemorrhage in an other- wise healthy 57-year old female who was recently started on apixiban for a provoked PE. She had been discharged from an outside facility, and presented just hours later to our emergency department in extremis: unconscious, pale, hypotensive, and tachycardic. Her abdo- men on arrival was noted to be distended, and bedside ultrasound con- firmed massive peritoneal fluid. Prompt diagnostic peritoneal aspirate confirmed hemoperitoneum, and a massive transfusion protocol was initiated. Initial hemoglobin and hematocrit were 4.2 g/dL and 13.4%, platelet count 204,000 per microliter. The patient’s prothrombin time and international normalized ratio were 19.5 s and 2.02. The patient re- ceived 4 units of Packed red blood cells, 1 unit of fresh frozen plasma, prothrombin complex concentrate, and calcium. The patient’s blood pressure, heart rate improved, and mental status improved. Computed tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen (Fig. 1). The patient was taken emergently to interventional radiology suite where splenic artery embolization was performed and an IVC filter was placed. She subsequently developed acute respiratory distress syndrome and

https://doi.org/10.1016/j.ajem.2019.12.006

0735-6757/(C) 2019

Fig. 1. Computed tomography demonstrated large subcapsular splenic hematoma with active extravasation at the periphery of the spleen.

persistent low urine output with hypotension despite resuscitation, and was taken to the operating room for splenectomy and abdominal wash- out. She improved thereafter and was discharged 12 days later.

Discussion

Prior work has characterized the atraumatic-pathologic splenic rup- ture in the case of neoplastic (30.3%), infectious (27.3%), inflammatory (20%), iatrogenic (9.2%), and mechanical (6.8%) processes, rarely in the case of a normal spleen (6.4%), and an overall mortality rate of 12.2% [1]. Mortality has been associated with advanced age, underlying neoplastic process, known preceding splenomegaly, and, especially, any Delay in diagnosis [2]. With the popularity of the NAOCs as well as evolving pharmacological strategies at Hemorrhage control (fresh fro- zen plasma, activated prothrombin concentrates, recombinant activated factor VII, idaricizumab), it is essential to recognize this rare but increas- ingly well-documented issue of atraumatic splenic rupture. Here we present the case of a previously healthy 57-year old, recently

anticoagulated for a provoked PE, presenting in shock. Prompt resusci- tation with blood products facilitated imaging which clarified her pa- thology, and splenic artery embolization temporized her until surgical exploration could be performed.

Conclusion

In this patient with spontaneous splenic hemorrhage after recent initiation of apixiban for a provoked PE, prompt diagnosis and aggres- sive early resuscitation contributed to a favorable outcome.

Declaration of competing interest

None.

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