Spontaneous rupture of malarial spleen: two case reports and review of literature

Abstract

Malaria has long been among the most common diseases in the southeast Anatolia region of Turkey. In 1992, 18676 cases were diagnosed in Turkey, and Diyarbakir city had the highest incidence (4168 cases), followed by SanliUrfa city (3578 cases). Malaria was especially common during 1994 and 1995, with 84 345 and 82 094 cases being diagnosed in these years, respectively. Spontaneous rupture of malarial spleen is rare. We saw two cases during 1998, which are reported herein. Both patients were male, and were receiving chloroquine treatment for an acute attack of malaria. One of the patients had developed abdominal pain and palpitations, followed by fainting. The other patient had abdominal pain and fever. Explorative laparotomy revealed an enlarged spleen in both patients. Splenectomy was performed in both patients. We have identified 15 episodes of spontaneous rupture of the spleen in the English language literature published since 1961. Because of increased travel to endemic areas and resistance to antimalarial drugs, malaria is a major medical problem that is becoming increasingly important to surgeons worldwide. Malaria is a particularly important problem in the southeast Anatolia region of Turkey. Prophylactic precautions should be taken by tourists who travel to this region, especially during the summer.

Introduction

]. We report two cases of spontaneous rupture of malarial spleen treated with splenectomy.

Case 1

. The patient, much improved, was discharged 6 days after the operation.

Case 2

was identified by thick film. The patient was discharged well 11 days after the operation.

Discussion

].

] quoted a figure of 800 000 deaths/year in African children during 1991.

].

].

].

].

]. The first of these mechanisms is increase in intrasplenic tension that is due to cellular hyperplasia and engorgement. Second, the spleen may be compressed by the abdominal musculature during physiological activities such as sneezing, coughing, defecation, and sitting up or turning in bed. Finally, vascular occlusion due to reticule endothelial hyperplasia, resulting in thrombosis and infarction, may be involved. This leads to interstitial and subcapsular haemorrhage and stripping of the capsule, which lead to further subcapsular haemorrhage. The distended capsule finally gives way.

Pathological findings in spontaneous rupture of the spleen include gross and microscopic changes. On gross examination, acutely malarial spleen is dark red because of congestion, hyperaemia and deposition of haemozoin (a malarial pigment). The capsule is thin and friable. Chronic malarial spleen tends to be dark grey, with increased density of connective tissue and fibrosis, resulting in a heavy, often massively enlarged organ with a firm or hard capsule. In addition, disruption of the spleen capsule and single or multiple tears in the underlying parenchyma may be found. Tears may be small or large (grades I-IV) and may be present on any surface. In both of the cases described above, the spleen was massively enlarged.

Microscopic examination demonstrated haemozoin, parasitized and uninfected erythrocytes, and a massive proliferation of macrophages throughout the capillaries, venous sinuses and pulp spaces. There is congestion and dilatation of sinuses and scattered thrombosis, with focal necrosis in capillaries and splenic pulp.

].

Reported cases of malaria in Turkey from 1992 to 1998

Reported cases of spontaneous rupture of malarial spleen since 1960

Reported herein.

Conclusion

appear to be important factors in spontaneous rupture of the spleen. Malaria is still important in the southeast Anatolia region of Turkey. Prophylactic measures should be taken by tourists who travel to this region, especially those who do so during the summer.

Keywords

• malaria
• prophylactic precautions
• ruptured spleen