Non-operative management of malarial splenic rupture: The Khartoum experience and an international review

Abstract

Malarial splenic rupture (MSR) occurs in a subset of patients and can be an acute surgical emergency. MSR is a well-known entity for more than 100 years, yet there are no well-structured studies in the literature that systematically evaluate this complication. While it has become increasingly recognized that splenic salvage can be vital to the long term immunity and health of these patients, there are few data to guide a safe approach to non-operative management of these patients. Current knowledge of spontaneous rupture of the spleen has been gained largely though reported cases. We present 2 cases of MSR and a review of the literature of the management of MSR. We present an algorithm for the management of MSR. Of the 60 cases of MSR in the literature 31 were managed with splenectomy, 21 were managed non-operatively, and 8 early deaths occurred during initial presentation. The most common presenting symptoms were fever (67%) and abdominal pain (51%). Seventy-two percent of patients were hypotensive and tachycardic on presentation. Fifteen (71%) of 21 patients had successful non-operative management for MSR. Of the six patients that failed non-operative treatment, 4 patients eventually needed splenectomy, and 2 patients died without operation. We recommend that patients presenting with fever, abdominal pain, hypotension, and spenomegaly receive urgent resuscitation, ultrasonography (where available) to evaluate for blood in the abdomen, and surgical consultation. Patients who are hemodynamically stable before or after resuscitation can be selectively chosen for non-operative management.

Spontaneous Rupture of Spleen in a Malaria Patient- A Case Report

“…Osman et al formulated a flowchart for the management of malarial splenic rupture after reviewing 252 cases previously reported in the literature [9]. This group emphasized the importance of non-operative management of hemodynamically stable patients but recommended splenectomy as a treatment for persistent hemodynamic instability.…”

Spontaneous Splenic Rupture in Malaria due to Plasmodium Ovale: A Case Report

“…Hyperactive Malarial Syndrome also known as Tropical Splenomegaly Syndrome is the first cause for splenomegaly in endemic regions. This Splenomegaly makes the spleen more fragile and more exposed to rupture [7,8].…”

“…Clinical presentation of SRS is not specific, delaying and often making diagnosis difficult. Left hypochondrial pain and systemic signs related to circulatory failure occurring during an attack of malaria are the most common presentations of splenic rupture [7,10].…”

“…However, conservative treatment is often preferred in patients hemodynamically stable as in the case in traumatic spleen rupture. Antimalarial treatment should always be associated in the management of spontaneous splenic rupture due to malaria parasites [5,7].…”

<p>Case Report: Sudden Splenic Rupture in a <em>Plasmodium falciparum</em>-Infected Patient</p>

“…Nevertheless, malarial splenic rupture (MSR) is a rare but lethal and dangerous complication of severe malarial infection with an estimated incidence of 2%. 6 , 7 This case has been published to generate awareness of such a spontaneous complication which could be potentially fatal if not diagnosed early. We present the case of a 74-year-old man with splenic rupture due to Plasmodium falciparum ( P. falciparum ) infection.…”