Rupture of the spleen is largely reported as an atraumatic sequelae of underlying conditions. Splenic cysts have an incidence of 0.07%. Complications from splenic cysts are rare—they may become symptomatic when enlarged, or rupture and cause peritonism. We describe a case of spontaneous rupture of splenic cyst progressing into subcapsular splenic hematoma with hemoperitoneum in a fit, young and healthy male. The patient underwent a splenectomy and recovered. The only abnormality identified was possible rupture from a benign epidermoid splenic cyst. Informed consent was obtained and patient anonymity preserved.

A 28-year-old man presented with a one-week of upper abdominal pain radiating to both shoulders and scapulae. He had no history of trauma, constitutional nor infective symptoms, and nil significant travel, medical and surgical history. He was a non-smoker with infrequent alcohol intake. While hemodynamically stable, he had generalized peritonism on examination, likely due to hemoperitoneum. This was confirmed via computed tomography (CT) angiography, which demonstrated a large subcapsular splenic hematoma measuring maximal 10 cm diameter with moderate hemoperitoneum (Figure 1). Computed tomography angiography also excluded vascular aneurysms, noting splenic cysts with possible septations, intracystic densities, and possible rupture. Splenic cysts were again identified on ultrasonography, with no discrete daughter cysts. Hydatid serology was non-reactive. Initial consultation to an interventional radiologist from a tertiary facility recommended conservative management. The patient required an analgesia pump and high-dependency care. A second opinion was sought from a senior surgeon the next day due to lack of clinical improvement. Given risks of rebleeding and subsequent splenic cyst and/or aneurysmal rupture/s, he underwent a splenectomy at day-three of admission (Figure 2). After approximately 1.2 L of hematoma evacuated, nil active bleeding was encountered intraoperatively. He made an uneventful postoperative recovery. He received post-splenectomy education, vaccinations and was discharged on long-term antibiotics. Histopathology revealed a benign 90×7848 mm epidermoid cyst of the spleen lined by stratified squamous epithelium, with possible partial cyst rupture and nil features of a hydatid cyst.

Atraumatic splenic rupture is usually secondary to underlying diseases—infectious diseases, hematological pathologies, and non-hematological malignancies. Colonoscopy is the most frequently associated procedure, whereas medications include anticoagulants, thrombolytics, and recombinant granulocyte-colony stimulating factor (G-CSF) [1],[2]. Abuse of alcohol and cocaine has been implied [3],[4].

Primary splenic cysts are rare, and complications from a splenic cyst are of greater rarity [5]. Fragandreas et al. described two cases of splenic rupture secondary to internal (coughing on background of asthma) and external (blunt abdominal injury) trauma with incidental findings of epithelial splenic cysts [6]. Splenic cysts may become symptomatic as they enlarge, and predispose to rupture and cause peritonism [5],[6],[7],[8],[9]. Symptoms vary but typically present as an acute abdomen, with left flank or upper quadrant pain radiating infrascapular or to the left shoulder [2],[3],[4] [5].

A hemoglobin drop and elevated tumor markers may be present [3],[4],[5],[8]. Computed tomography angiography is diagnostic, delineating splenic infarct versus rupture, and may detect underlying causes [2],[3],[4],[10]. Splenectomy is usually indicated in rupture of splenic cyst. Drainage, cyst excision, and laparoscopic fenestration are other options [2],[6],[7].

Splenic rupture can occur in an atraumatic setting, and in young, fit, and healthy individuals. Computed tomography continues to be the most suitable imaging modality in cases presenting with acute abdomen, and splenectomy recommended as treatment in splenic rupture.