2493 Large Perisplenic Hematoma and Spontaneous Hemoperitoneum as the Initial Presentation of Undiagnosed Burkitt's Lymphoma

Abstract

INTRODUCTION: Spontaneous hemoperitoneum (SH) is a rare but life-threatening condition of non-traumatic etiology. It usually arises from spleen, hepatic, gynecologic and vascular sources. CASE DESCRIPTION/METHODS: A 61-year-old male with no known medical history presented with acute left sided, non-radiating abdominal pain. On examination, he was hemodynamically stable and had a soft, non-tender abdomen with splenomegaly. His laboratory workup was significant for pancytopenia. CT of abdomen showed a 9 cm perisplenic hematoma with moderate ascites. Patient was admitted to ICU for closer monitoring and a follow-up contrast enhanced CT of abdomen confirmed a perisplenic hematoma and revealed splenomegaly measuring 20 cm with the presence of hemoperitoneum. Sclerotic lesions in multiple thoracolumbar vertebrae, sacrum, and right iliac bone, suspicious for metastasis were also found. Follow-up chest CT revealed mildly enlarged mediastinal lymph nodes. His bone scan was negative. Further malignancy workup was remarkable for a low haptoglobin and high LDH levels. Flow cytometry was positive for CD4, CD5, CD10 and CD19 consistent with B cell lymphoma. Chromosomal analysis confirmed a translocation t(8;14) and FISH analysis showed fusion of MYC and IGH genes in 15.5% of cells, consistent with BL. The patient was managed conservatively. DISCUSSION: The exact mechanism of non-traumatic splenic hematoma leading to hemoperitoneum is unclear. One theory is an increased intra-splenic pressure due to endothelial hyperplasia and vascular occlusion due to a hypercoaguble state leading to spontaneous bleeding from leaking capillaries. Diagnosis is unsuspected and mainly made by CT as seen in our patient whose only findings included abdominal pain and pancytopenia. There have been very few reported cases in literature of SH and even fewer in patients with diagnosed BL. All such cases involved a ruptured spleen. Our patient is unique and to the best of our knowledge, the first ever reported case of SH presenting as an initial feature of a previously undiagnosed BL. Furthermore, his hemoperitoneum was secondary to a large perisplenic hematoma with an intact but enlarged spleen. Therefore, it is important for clinicians to keep lymphoma as a differential in patients presenting with acute abdominal pain and pancytopenia in order to effectively diagnose and treat an underlying malignancy and prevent future complications.