Atraumatic splenic rupture in a patient treated with rivaroxaban: a case report and a narrative review.

Authors: Labaki M.-L.*; De Kock M.**

*Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium. E-mail:labaki.ml@gmail.com

**Department of Intensive Care, Centre Hospitalier de Wallonie Picarde (CHwapi), Tournai, Belgium. E-mail:marcdekock1888@gmail.com

Abstract:

Introduction : Atraumatic splenic rupture (ASR) is rare, mostly associated with neoplastic, infectious and inflammatory diseases. ASR related to drug treatment is infrequent. In this case report we highlight an unusual complication of the direct oral anticoagulant rivaroxaban.

Case presentation : A 64-year-old male patient was admitted in the emergency department for lipothymic illness on diffuse abdominal cramps. There is no history of recent trauma. The clinical examination showed hemodynamic instability with moderate response to filling and a mild abdominal discomfort on palpation. His medical history included chronic hypertension, chronic constipation and a recent atrial flutter ablation. He was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban 20 mg. The diagnosis of splenic rupture was made several hours later with an abdominal CT scan with contrast injection. A massive blood transfusion and an emergency laparotomy for splenectomy were performed. The anatomopathological analysis did not reveal any cause of neoplastic, inflammatory or infectious cause. The patient was successfully discharged from intensive care unit 3 days later.

Conclusion : Clinicians must remember the potential ASR as complication due to direct oral anticoagulants when they are confronted to a patient with abdominal tenderness and hemodynamical instability. Unfortunately, the clinical presentation is not always typical of a ruptured spleen. Delayed diagnosis can be life-threatening and fatal. Splenectomy by laparotomy remain the best therapeutic option in case of splenic rupture in unstable patients on direct oral anticoagulants.

Keywords: atraumatic splenic rupture, rivaroxaban, direct oral anticoagulant, spontaneous splenic rupture, apixaban, dabigatran, betrixaban, edoxaban.

Introduction:

The abdominal trauma is a well-known cause of splenic rupture [1]. The major problem in atraumatic splenic rupture (ASR) is the missed or delayed diagnosis and consequently, delayed management leading to fatal outcome. In case of ASR, the mortality rate is around 12,2%. [2] Several systematic reviews of the literature reported that the main etiologies are infectious, neoplastic and inflammatory. The drug-related cause is even more rare [3][4]. Since the emergence of direct oral anticoagulants (DOAC) at the beginning of the 21st century, physicians are increasingly confronted with their adverse effects and complications. In this article we describe a case of ASR in a patient treated with rivaroxaban according to CARE guidelines [5]. Then, we made a narrative review of the literature by searching until June 2022 other similar cases in the Pubmed and Google scholardatabases with relevant keywords. Only cases written in French and English were retained. We compared them and looked for factors promoting splenic rupture and bleeding in patients taking rivaroxaban and other DOAC.

Case presentation:

A 64-years-old male patient was admitted in the emergency department for lipothymic illness on diffuse abdominal cramps. His medical history included chronic hypertension, chronic constipation and an atrial flutter ablation 6 days before. He was taking amiodarone, bisoprolol, atorvastatin, and rivaroxaban 20 mg. There is no history of trauma or infections in the previous months. Moreover, the patient has limited contact with the outside world because of the covid-19 pandemic. His parameters were a blood pressure at 85/55 mmHg, a sinusal cardiac rate at 76 beats per minute, an oxygen saturation level of 99% on room air and a normal body temperature. The physical examination highlighted a normal cardiopulmonary auscultation, a mild diffuse abdominal tenderness at the palpation without guarding or irradiation.

He underwent several complementary tests. His blood tests (hemoglobin, white blood cells, coagulation, ionogram, liver and kidney functions) came back normal (Table 1). There was no increase in lactate on the arterial blood gases. The urine spot is without particularity. The PCR test for covid 19 is negative. The electrocardiogram shows a sinusal rythm with a frequence around 70 beats per minute and no repolarisation troubles.