Pathological rupture of the spleen in malaria: Analysis of 55 cases (1958–2008)

doi:10.1016/j.tmaid.2009.01.002

Travel Medicine and Infectious Disease

Volume 7, Issue 3, May 2009, Pages 147-159

https://doi.org/10.1016/j.tmaid.2009.01.002 Get rights and content

Summary

Background

Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated.

Method

We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages.

Results

Fifty-five cases were reported, due to Plasmodium falciparum (n = 26), Plasmodium vivax (n = 23), Plasmodium ovale (n = 2), Plasmodium malariae (n = 2), or P. vivax–falciparum (n = 2), and occurred in travellers (n = 24), locals (n = 21), expatriates (n = 6) or migrants (n = 4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n = 50), or partial (n = 5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n = 7) or unexpected death (n = 1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p = 0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n = 14), immediate splenectomy (n = 29), delayed splenectomy (n = 4), or none (patients dying at admission, n = 8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5–6 days) than in previous reports on imported malaria (3–4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture.

Conclusions

Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.

Introduction

Malaria is one of the most serious tropical diseases. According to World Health Organization (WHO) estimates, 300–500 million humans suffer from malaria each year, of whom more than 1 million die.¹ Almost all deaths are due to severe and complicated Plasmodium falciparum infection, so-defined by WHO severity criteria.² In highly endemic areas of Africa, malaria contributes indirectly to a number of additional deaths through low birth weight in babies born from mothers infected with P. falciparum during pregnancy (gestational malaria).³

Splenic rupture is another, less well known life-threatening malaria complication. Despite long clinical experience,⁴ its epidemiological and clinical features are still poorly understood. No prospective standardized sources of data are available. Advances in knowledge of the role of the spleen in malaria have not provided significant insights into the putative mechanisms of splenic rupture. The optimum therapeutic management continues to be debated. Specifically, uniform criteria to guide between immediate splenectomy and in-hospital medical observation (i.e., conservative management) do not exist. In an attempt to clarify these issues, we analysed published data on pathological splenic rupture during malaria as thoroughly as possible. We collected Case Reports (no series of cases were found) published over the last 50 years in five languages. Demographic, clinical and parasitological characteristics were extracted, analysed and commented on.

Section snippets

Information collection

We conducted a Medline search for all reports published over the past 50 years, using the key-words ‘spontaneous rupture of the spleen, splenic rupture, malaria’, and restricted to reports in English, German, French, Spanish, and Portuguese. Publications on imported malaria deaths in non-endemic countries were also reviewed and authors who had reported deaths due to splenic rupture were contacted for more details. We excluded ‘spontaneous’ splenic rupture in malaria prior to 1958 and traumatic

Epidemiological data

We found 55 reports of ‘spontaneous’ splenic rupture due to malaria published from 1958 to 2008.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43 Main characteristics of these cases are shown in Table 1. The median age was 31.5 years (range: 3–80, information lacking in 1 case). Five patients (9.1%) were children (0–15 years)6, 7, 8, 9, 10 and 1 (1.9%) was elderly.¹¹ Forty-two were males and 13

Terminology

‘Spontaneous splenic rupture’ was the most frequent expression used in the literature to describe splenic rupture in the absence of recent trauma to the left abdomen. However, the published expression that best reflects the key features of this complication is “pathological rupture” of the spleen.27, 28 The general phenomenon is indeed analogous to the pathological fracture of a bone fragilized by an underlying disease. Better than “spontaneous rupture”, “pathological rupture” implies both the

Conflict of interest

The authors have no competing interests to declare.

Acknowledgements

We would like to thank the CDCs of Atlanta and all authors who have kindly given us details on their personal cases or permitting us to reproduce their pictures. We also thank Dr. Nesemann for linguistic assistance.

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Invited submissionPathological rupture of the spleen in malaria: Analysis of 55 cases (1958–2008)

Summary

Background

Method

Results

Conclusions

Introduction

Section snippets

Information collection

Epidemiological data

Terminology

Conflict of interest

Acknowledgements

Lancet Infect Dis

Am J Med

Lancet

J Chir (Paris)

Acta Trop

Rev Med Interne

Blood

Blood

Trans R Soc Trop Med Hyg

Clin Radiol

Med Mal Infect

Injury

Ann Chir

Trans R Soc Trop Med Hyg

Lancet Infect Dis

Trans R Soc Trop Med Hyg

Clin Microbiol Infect

Trans R Soc Trop Med Hyg

Blood

Infect Dis Clin North Am

The limits and intensity of Plasmodium falciparum transmission: implications for malaria control and elimination worldwide

PLoS Med

Improving case definitions for severe malaria

PLoS Med

Spontaneous rupture of the spleen

Trop Dis Bull

Rupture of the spleen in rural parts of Egypt

Am J Surg

Malaria surveillance annual summary

Malaria surveillance annual summary

Spontaneous rupture of the spleen during malaria: a conservative treatment is appropriate for selected patients

Clin Infect Dis

Spontaneous rupture of spleen in falciparum malaria

Indian J Gastroenterol

Spontaneous rupture of malarial spleen

Indian Pediatr

Med Trop (Mars)

Spontaneous splenic rupture in vivax malaria: case report

Mil Med

Spontaneous rupture of the pathological spleen in malaria

S Afr Med J

Rupture of spleen in a mechanically ventilated patient with falciparum malaria admitted with pulmonary edema

Saudi Med J

Chronic malaria with splenic rupture

J Travel Med

The clinical spectrum of severe imported falciparum malaria in the intensive care unit: report of 188 cases in adults

Am J Respir Crit Care Med

Rev Cubana Med Trop

Spontaneous rupture of the spleen during malaria treated with transcatheter coil embolization of the splenic artery

Intensive Care Med

Non-operative management of a spontaneously ruptured malarial spleen

Br J Surg

Malaria surveillance annual summary

Presse Med

Invited submission
Pathological rupture of the spleen in malaria: Analysis of 55 cases (1958–2008)