Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review

Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review Rodrigo Furlan Silva Fabri, Anvitha Soundararajan, Lela Ruck, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7103532/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Atraumatic splenic rupture (ASR) is a rare but life-threatening clinical condition typically associated with hematologic malignancies. Among these, diffuse large B-cell lymphoma (DLBCL) is an aggressive subtype of non-Hodgkin lymphoma that commonly presents with lymphadenopathy or systemic symptoms. ASR as the initial presentation of DLBCL is exceedingly rare but represents a critical diagnostic and therapeutic challenge. Case Presentation: We report the case of a 61-year-old hispanic male with a history of hypertension and hyperlipidemia who presented with acute left upper-quadrant abdominal pain, hypotension, and symptoms of hypovolemic shock. He denied recent trauma but reported unintentional weight loss over six months. Physical exam revealed splenomegaly and localized tenderness. Laboratory studies showed anemia, elevated lactate, and leukocytosis. Contrast-enhanced CT imaging demonstrated massive splenomegaly, perisplenic hemorrhage, and parenchymal lacerations, consistent with spontaneous splenic rupture. The patient underwent emergent splenectomy and received extensive transfusion support. Histopathological analysis confirmed a diagnosis of DLBCL with high proliferative index. Staging PET scan revealed disseminated disease involving lymph nodes, liver, and bone marrow (Ann Arbor stage IV). Despite initiation of R-CHOP chemotherapy, the patient experienced rapid clinical decline and died six weeks after presentation. Conclusions: This case highlights ASR as a rare and catastrophic initial presentation of DLBCL. Early recognition, rapid imaging, and surgical intervention are crucial to patient survival. However, the presence of disseminated disease and underlying tumor biology significantly affect prognosis. Clinicians should maintain high suspicion for ASR in lymphoma patients presenting with sudden abdominal pain and hemodynamic instability, even in the absence of trauma. Awareness of this rare presentation may enable earlier diagnosis and improve clinical outcomes. Atraumatic splenic rupture Diffuse large B-cell lymphoma Non-Hodgkin lymphoma Splenectomy Hematologic malignancy case report Figures Figure 1 Figure 2 Background Atraumatic splenic rupture (ASR) is a rare but potentially fatal clinical entity, which is associated with various underlying pathological conditions. Among the various etiologies, hematologic malignancies—including non-Hodgkin lymphoma (NHL), leukemia, and other infiltrative disorders—constitute a significant proportion of reported cases [ 1 ]. Although trauma is the predominant cause of splenic rupture in general, ASR has emerged as an important differential diagnosis in patients presenting with sudden abdominal pain and hemodynamic instability in the absence of trauma. Diffuse large B-cell lymphoma (DLBCL), the most common subtype of NHL, typically presents with rapidly enlarging lymphadenopathy, extranodal involvement, or systemic “B” symptoms. ASR as the initial manifestation of DLBCL is exceedingly rare [ 2 , 3 ]. The spleen, being highly vascular and immunologically active, can become significantly infiltrated by malignant lymphocytes, leading to marked splenomegaly. The resultant capsular tension and parenchymal friability render it susceptible to spontaneous rupture [ 4 ]. This case report describes a patient with previously undiagnosed DLBCL who presented with ASR as the initial manifestation. We aim to underscore the importance of prompt recognition, early imaging, and surgical intervention in such scenarios. Furthermore, we discuss the pathophysiology, risk factors, and clinical implications of ASR in hematologic malignancies, with particular emphasis on DLBCL. Case Report A 61-year-old male with a medical history of hypertension and hyperlipidemia presented to the emergency department with abrupt-onset, severe left upper-quadrant abdominal pain. The pain was non-radiating, progressively worsened over several hours, and was accompanied by dizziness and profound weakness. He also endorsed unintentional weight loss over the past six months but had not been previously evaluated for this weight loss. Upon presentation, the patient appeared acutely ill. Vital signs revealed hypotension (BP: 90/50 mmHg), tachycardia (HR: 120 bpm), and diaphoresis. He exhibited signs of hypovolemic shock. Physical examination demonstrated localized tenderness in the left upper quadrant without rebound or guarding. Splenomegaly was noted on initial evaluation. No palpable masses or lymphadenopathy were noted on initial evaluation. Initial laboratory workup showed a hemoglobin of 9.8 g/dL and serum lactate of 4.2 mmol/L (elevated), suggestive of tissue hypoperfusion. The white blood cell count was mildly elevated at 13.5 × 10⁹/L; platelet count and coagulation parameters were within normal limits. Renal and hepatic function panels were unremarkable. Given the hemodynamic instability and suspicion of intra-abdominal hemorrhage, an urgent contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was obtained. Imaging revealed a markedly enlarged spleen measuring approximately 20 cm in craniocaudal dimension, with perisplenic fluid, parenchymal lacerations, and subcapsular hematoma—findings diagnostic of splenic rupture (Figs. 1 and 2). Additional findings included multiple enlarged intra-abdominal lymph nodes and a 4 cm axillary lymph node. Hypodense lesions were also visualized within the liver parenchyma, raising concern for metastatic involvement. The patient was taken emergently to the operating room for exploratory laparotomy. Intraoperatively, the spleen was found to be ruptured with extensive hemoperitoneum. A splenectomy was performed, and he received intraoperative transfusions totaling 10 units of packed red blood cells, 4 units of fresh frozen plasma, and 6 units of platelets. Postoperative complications included hospital-acquired pneumonia and a mild pancreatic duct leak, which required percutaneous drainage. He remained in the intensive care unit for 12 days for treatment and recovery from these complications. Histopathologic examination of the spleen confirmed the diagnosis of diffuse large B-cell lymphoma. Immunohistochemistry was positive for CD19, CD20, and CD79a, consistent with B-cell lineage. The Ki-67 proliferation index was markedly elevated, indicating a high-grade lymphoma. Staging with positron emission tomography (PET) demonstrated hypermetabolic activity in multiple lymph node regions, liver lesions, and diffuse bone marrow involvement, consistent with Ann Arbor stage IV disease. The patient was referred to oncology and began standard immunochemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Unfortunately, despite appropriate oncologic management, his clinical condition progressively declined, and he succumbed to his disease six weeks after the initial presentation. Discussion Atraumatic splenic rupture (ASR) is an uncommon but clinically significant complication associated with hematologic malignancies. Among these, DLBCL has been sporadically documented as a cause of spontaneous rupture, typically in cases of advanced disease with massive splenomegaly [ 2 , 5 ]. The underlying mechanism is hypothesized to involve parenchymal infiltration by malignant lymphocytes, which leads to splenic congestion, vascular fragility, and ultimately rupture of the capsule [ 6 ]. This is further exacerbated by neovascularization within the spleen and associated microinfarcts that compromise structural integrity [ 7 ]. Several predisposing factors have been associated with ASR in lymphoma patients: Massive splenomegaly: Increases capsular tension and predisposes to rupture [ 4 , 6 ]. Malignant infiltration: Replaces normal architecture, reducing splenic elasticity [ 1 , 3 ]. Coagulopathies or thrombocytopenia: Often secondary to bone marrow suppression or chemotherapy [ 5 , 8 ]. Splenic infarction: Results in necrosis and weakening of the splenic capsule [ 6 ]. Vascular engorgement and hyperemia: Associated with aggressive neoplastic proliferation [ 4 , 7 ]. The clinical presentation is often nonspecific, with symptoms including acute abdominal pain, referred shoulder pain (Kehr’s sign), nausea, dizziness, and hemodynamic instability [ 2 , 9 ]. The absence of trauma history may delay diagnosis, making prompt imaging—typically CT—the cornerstone of evaluation. Once ASR is suspected, immediate surgical consultation is warranted [ 10 ]. While non-operative management may be considered in hemodynamically stable patients with traumatic splenic injury, ASR secondary to malignancy typically mandates urgent surgical intervention due to ongoing hemorrhage and friable splenic tissue [ 9 , 10 ]. Splenectomy remains the definitive treatment, often accompanied by aggressive volume resuscitation and transfusion support [ 3 , 5 ]. Despite successful surgical intervention, the overall prognosis in patients with ASR due to aggressive lymphomas remains guarded [ 8 , 9 ]. The course is predominantly dictated by the extent and behavior of the underlying malignancy. In this case, despite timely splenectomy and initiation of chemotherapy, the patient’s disease burden was extensive, and he succumbed to progressive lymphoma. Early identification of ASR in the setting of hematologic malignancy is paramount. Clinicians should maintain a high index of suspicion in lymphoma patients presenting with unexplained abdominal pain, hypotension, or anemia—particularly in those with known splenomegaly [ 1 , 2 , 4 ]. Prompt imaging, surgical management, and initiation of definitive oncologic therapy can offer the best chance for survival, although outcomes remain variable and depend largely on disease stage and tumor biology [ 6 , 9 ]. Conclusion Atraumatic splenic rupture represents a rare but potentially fatal initial manifestation of diffuse large B-cell lymphoma. This case underscores the importance of early recognition, high clinical suspicion, and rapid surgical intervention in patients with unexplained abdominal pain and signs of hemorrhagic shock. While splenectomy can be life-saving, the prognosis ultimately hinges on the extent of the underlying malignancy. Awareness of ASR as a differential diagnosis in hematologic malignancy patients is critical for timely diagnosis and improved clinical outcomes. Abbreviations ASR – Atraumatic Splenic Rupture BP – Blood Pressure CT – Computed Tomography DLBCL – Diffuse Large B-Cell Lymphoma HR – Heart Rate ICU – Intensive Care Unit NHL – Non-Hodgkin Lymphoma PET – Positron Emission Tomography R-CHOP – Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone Declarations Ethics approval and consent to participate Not applicable. Ethics approval was not required for this case report in accordance with institutional policy. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials All data generated or analyzed during this case report are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Clinical trial number: not applicable Authors’ contributions RFSF,AS,LR,GR conceived the case report, collected the clinical data, and drafted the manuscript. LR,GR reviewed and revised the manuscript for intellectual content. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the surgical and pathology teams involved in the patient's care. References O’Sullivan TG, Simson WL. Spontaneous splenic rupture in hematologic malignancies: A review. Am J Hematol. 2022;97(2):204-212. doi:10.1002/ajh.26484. Renzulli P, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg. 2020;107(3):233-241. doi:10.1002/bjs.11523. Sorrentino P, Pomara C. Atraumatic splenic rupture in non-Hodgkin lymphoma: A case report and review of the literature. Case Rep Hematol. 2021;2021:4235673. doi:10.1155/2021/4235673. Proskuriakova E, Polozov A. Atraumatic splenic rupture as an unusual presentation of lymphoma. J Clin Oncol. 2023;41(6):704-708. doi:10.1200/JCO.22.01134. Sandhu M, Singh A. Hematologic malignancies and splenic rupture: A review of mechanisms, management, and prognosis. J Hematol Oncol. 2020;13(1):97. doi:10.1186/s13045-020-00947-7. Zhong Y, Liu Y. Diffuse large B-cell lymphoma with spontaneous splenic rupture: A case report. BMC Hematol. 2021;21(1):72. doi:10.1186/s12878-021-00335-6. Krishnan N, Patel D. Spontaneous rupture of the spleen in a patient with aggressive B-cell lymphoma. J Clin Pathol. 2020;73(4):221-225. doi:10.1136/jclinpath-2020-2068. Thompson DM, Wang M. Splenic rupture in lymphoma: An uncommon but deadly complication. J Emerg Med. 2019;56(5):667-673. doi:10.1016/j.jemermed.2019.01.012. Dubey P, Le L. Spontaneous splenic rupture in non-Hodgkin lymphoma: Pathophysiology and management. Blood Cancer J. 2022;12(1):19. doi:10.1038/s41408-021-00591-x. Thompson AJ, Hoang MP. Management of traumatic and atraumatic splenic rupture: A review. J Clin Surg. 2021;89(3):120-126. doi:10.1097/JSU.0000000000000269. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7103532","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":489030127,"identity":"69fca516-04cf-4548-aaef-787f7db41516","order_by":0,"name":"Rodrigo Furlan Silva Fabri","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center El Paso","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"Furlan Silva","lastName":"Fabri","suffix":""},{"id":489030128,"identity":"12b13a63-94c3-4899-a22e-e7107b4f2f28","order_by":1,"name":"Anvitha Soundararajan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYJCCA4wNUBYPA4McWOQBIS0HkbQYg0USCFmDrCURzManhX92j+HhjzvsGOTbe8wevKm5lz4/7PBDoC12croN2LVI3DljcODgmWQGgzNnzA3nHCvO3Xg7zQCoJdnY7AAOa26kJRw42MbMYCCRYybNw5aQu3F2AkjLgcRtOLTIQ7TUM8jPAGn5l5BuODv9A14tBjeSDwC1HAZaB9TC25aQIC+dg98WQ5CWs23HeQzOHCuTnNuXYLhBOqfgQIIBbr/I3Uhs/lDZVi0n3968TeLNtwR5+dnpmz98qLCTw+l9KOBBOBWs0gC/clQg30CK6lEwCkbBKBgJAAAormcyJnvN4QAAAABJRU5ErkJggg==","orcid":"","institution":"Texas Tech University Health Sciences Center El Paso","correspondingAuthor":true,"prefix":"","firstName":"Anvitha","middleName":"","lastName":"Soundararajan","suffix":""},{"id":489030129,"identity":"de66ddb1-4c56-4c7c-95fb-36cae1c12c94","order_by":2,"name":"Lela Ruck","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center El Paso","correspondingAuthor":false,"prefix":"","firstName":"Lela","middleName":"","lastName":"Ruck","suffix":""},{"id":489030130,"identity":"1d535555-69f2-4082-9cb9-ef32b3fafebd","order_by":3,"name":"Gowri Renganathan","email":"","orcid":"","institution":"Texas Tech University Health Sciences Center El Paso","correspondingAuthor":false,"prefix":"","firstName":"Gowri","middleName":"","lastName":"Renganathan","suffix":""}],"badges":[],"createdAt":"2025-07-11 16:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7103532/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7103532/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87576865,"identity":"35234152-e0b3-4679-b546-b4894dbdd648","added_by":"auto","created_at":"2025-07-25 11:46:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":401229,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"ctabdpelvis.png","url":"https://assets-eu.researchsquare.com/files/rs-7103532/v1/896824d54f30928b745d61af.png"},{"id":87575438,"identity":"9827867e-9031-4a9c-ad60-04eb734b1f34","added_by":"auto","created_at":"2025-07-25 11:38:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":399559,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"ctabdpel2.png","url":"https://assets-eu.researchsquare.com/files/rs-7103532/v1/7c15ece3f7cac3ea5fa66444.png"},{"id":90005219,"identity":"0f06045a-5e60-4d30-9921-ac201972c2dd","added_by":"auto","created_at":"2025-08-27 09:25:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1464155,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7103532/v1/79044b60-25f5-4996-b8f7-6373212075eb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review","fulltext":[{"header":"Background","content":"\u003cp\u003eAtraumatic splenic rupture (ASR) is a rare but potentially fatal clinical entity, which is associated with various underlying pathological conditions. Among the various etiologies, hematologic malignancies—including non-Hodgkin lymphoma (NHL), leukemia, and other infiltrative disorders—constitute a significant proportion of reported cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although trauma is the predominant cause of splenic rupture in general, ASR has emerged as an important differential diagnosis in patients presenting with sudden abdominal pain and hemodynamic instability in the absence of trauma.\u003c/p\u003e\u003cp\u003eDiffuse large B-cell lymphoma (DLBCL), the most common subtype of NHL, typically presents with rapidly enlarging lymphadenopathy, extranodal involvement, or systemic “B” symptoms. ASR as the initial manifestation of DLBCL is exceedingly rare [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The spleen, being highly vascular and immunologically active, can become significantly infiltrated by malignant lymphocytes, leading to marked splenomegaly. The resultant capsular tension and parenchymal friability render it susceptible to spontaneous rupture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis case report describes a patient with previously undiagnosed DLBCL who presented with ASR as the initial manifestation. We aim to underscore the importance of prompt recognition, early imaging, and surgical intervention in such scenarios. Furthermore, we discuss the pathophysiology, risk factors, and clinical implications of ASR in hematologic malignancies, with particular emphasis on DLBCL.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 61-year-old male with a medical history of hypertension and hyperlipidemia presented to the emergency department with abrupt-onset, severe left upper-quadrant abdominal pain. The pain was non-radiating, progressively worsened over several hours, and was accompanied by dizziness and profound weakness. He also endorsed unintentional weight loss over the past six months but had not been previously evaluated for this weight loss.\u003c/p\u003e\u003cp\u003eUpon presentation, the patient appeared acutely ill. Vital signs revealed hypotension (BP: 90/50 mmHg), tachycardia (HR: 120 bpm), and diaphoresis. He exhibited signs of hypovolemic shock. Physical examination demonstrated localized tenderness in the left upper quadrant without rebound or guarding. Splenomegaly was noted on initial evaluation. No palpable masses or lymphadenopathy were noted on initial evaluation.\u003c/p\u003e\u003cp\u003eInitial laboratory workup showed a hemoglobin of 9.8 g/dL and serum lactate of 4.2 mmol/L (elevated), suggestive of tissue hypoperfusion. The white blood cell count was mildly elevated at 13.5 × 10⁹/L; platelet count and coagulation parameters were within normal limits. Renal and hepatic function panels were unremarkable.\u003c/p\u003e\u003cp\u003eGiven the hemodynamic instability and suspicion of intra-abdominal hemorrhage, an urgent contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was obtained. Imaging revealed a markedly enlarged spleen measuring approximately 20 cm in craniocaudal dimension, with perisplenic fluid, parenchymal lacerations, and subcapsular hematoma—findings diagnostic of splenic rupture (Figs.\u0026nbsp;1 and 2). Additional findings included multiple enlarged intra-abdominal lymph nodes and a 4 cm axillary lymph node. Hypodense lesions were also visualized within the liver parenchyma, raising concern for metastatic involvement.\u003c/p\u003e\u003cp\u003eThe patient was taken emergently to the operating room for exploratory laparotomy. Intraoperatively, the spleen was found to be ruptured with extensive hemoperitoneum. A splenectomy was performed, and he received intraoperative transfusions totaling 10 units of packed red blood cells, 4 units of fresh frozen plasma, and 6 units of platelets. Postoperative complications included hospital-acquired pneumonia and a mild pancreatic duct leak, which required percutaneous drainage. He remained in the intensive care unit for 12 days for treatment and recovery from these complications.\u003c/p\u003e\u003cp\u003eHistopathologic examination of the spleen confirmed the diagnosis of diffuse large B-cell lymphoma. Immunohistochemistry was positive for CD19, CD20, and CD79a, consistent with B-cell lineage. The Ki-67 proliferation index was markedly elevated, indicating a high-grade lymphoma. Staging with positron emission tomography (PET) demonstrated hypermetabolic activity in multiple lymph node regions, liver lesions, and diffuse bone marrow involvement, consistent with Ann Arbor stage IV disease.\u003c/p\u003e\u003cp\u003eThe patient was referred to oncology and began standard immunochemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Unfortunately, despite appropriate oncologic management, his clinical condition progressively declined, and he succumbed to his disease six weeks after the initial presentation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAtraumatic splenic rupture (ASR) is an uncommon but clinically significant complication associated with hematologic malignancies. Among these, DLBCL has been sporadically documented as a cause of spontaneous rupture, typically in cases of advanced disease with massive splenomegaly [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The underlying mechanism is hypothesized to involve parenchymal infiltration by malignant lymphocytes, which leads to splenic congestion, vascular fragility, and ultimately rupture of the capsule [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This is further exacerbated by neovascularization within the spleen and associated microinfarcts that compromise structural integrity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral predisposing factors have been associated with ASR in lymphoma patients:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMassive splenomegaly: Increases capsular tension and predisposes to rupture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMalignant infiltration: Replaces normal architecture, reducing splenic elasticity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCoagulopathies or thrombocytopenia: Often secondary to bone marrow suppression or chemotherapy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSplenic infarction: Results in necrosis and weakening of the splenic capsule [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eVascular engorgement and hyperemia: Associated with aggressive neoplastic proliferation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe clinical presentation is often nonspecific, with symptoms including acute abdominal pain, referred shoulder pain (Kehr\u0026rsquo;s sign), nausea, dizziness, and hemodynamic instability [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The absence of trauma history may delay diagnosis, making prompt imaging\u0026mdash;typically CT\u0026mdash;the cornerstone of evaluation. Once ASR is suspected, immediate surgical consultation is warranted [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile non-operative management may be considered in hemodynamically stable patients with traumatic splenic injury, ASR secondary to malignancy typically mandates urgent surgical intervention due to ongoing hemorrhage and friable splenic tissue [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Splenectomy remains the definitive treatment, often accompanied by aggressive volume resuscitation and transfusion support [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite successful surgical intervention, the overall prognosis in patients with ASR due to aggressive lymphomas remains guarded [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The course is predominantly dictated by the extent and behavior of the underlying malignancy. In this case, despite timely splenectomy and initiation of chemotherapy, the patient\u0026rsquo;s disease burden was extensive, and he succumbed to progressive lymphoma.\u003c/p\u003e\u003cp\u003eEarly identification of ASR in the setting of hematologic malignancy is paramount. Clinicians should maintain a high index of suspicion in lymphoma patients presenting with unexplained abdominal pain, hypotension, or anemia\u0026mdash;particularly in those with known splenomegaly [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Prompt imaging, surgical management, and initiation of definitive oncologic therapy can offer the best chance for survival, although outcomes remain variable and depend largely on disease stage and tumor biology [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAtraumatic splenic rupture represents a rare but potentially fatal initial manifestation of diffuse large B-cell lymphoma. This case underscores the importance of early recognition, high clinical suspicion, and rapid surgical intervention in patients with unexplained abdominal pain and signs of hemorrhagic shock. While splenectomy can be life-saving, the prognosis ultimately hinges on the extent of the underlying malignancy. Awareness of ASR as a differential diagnosis in hematologic malignancy patients is critical for timely diagnosis and improved clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASR \u0026ndash; Atraumatic Splenic Rupture\u003c/p\u003e\n\u003cp\u003eBP \u0026ndash; Blood Pressure\u003c/p\u003e\n\u003cp\u003eCT \u0026ndash; Computed Tomography\u003c/p\u003e\n\u003cp\u003eDLBCL \u0026ndash; Diffuse Large B-Cell Lymphoma\u003c/p\u003e\n\u003cp\u003eHR \u0026ndash; Heart Rate\u003c/p\u003e\n\u003cp\u003eICU \u0026ndash; Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eNHL \u0026ndash; Non-Hodgkin Lymphoma\u003c/p\u003e\n\u003cp\u003ePET \u0026ndash; Positron Emission Tomography\u003c/p\u003e\n\u003cp\u003eR-CHOP \u0026ndash; Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. Ethics approval was not required for this case report in accordance with institutional policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All data generated or analyzed during this case report are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRFSF,AS,LR,GR conceived the case report, collected the clinical data, and drafted the manuscript. LR,GR reviewed and revised the manuscript for intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThe authors would like to thank the surgical and pathology teams involved in the patient\u0026apos;s care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eO\u0026rsquo;Sullivan TG, Simson WL. Spontaneous splenic rupture in hematologic malignancies: A review. Am J Hematol. 2022;97(2):204-212. doi:10.1002/ajh.26484.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRenzulli P, Candinas D. Systematic review of atraumatic splenic rupture. Br J Surg. 2020;107(3):233-241. doi:10.1002/bjs.11523.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSorrentino P, Pomara C. Atraumatic splenic rupture in non-Hodgkin lymphoma: A case report and review of the literature. Case Rep Hematol. 2021;2021:4235673. doi:10.1155/2021/4235673.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProskuriakova E, Polozov A. Atraumatic splenic rupture as an unusual presentation of lymphoma. J Clin Oncol. 2023;41(6):704-708. doi:10.1200/JCO.22.01134.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSandhu M, Singh A. Hematologic malignancies and splenic rupture: A review of mechanisms, management, and prognosis. J Hematol Oncol. 2020;13(1):97. doi:10.1186/s13045-020-00947-7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZhong Y, Liu Y. Diffuse large B-cell lymphoma with spontaneous splenic rupture: A case report. BMC Hematol. 2021;21(1):72. doi:10.1186/s12878-021-00335-6.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKrishnan N, Patel D. Spontaneous rupture of the spleen in a patient with aggressive B-cell lymphoma. J Clin Pathol. 2020;73(4):221-225. doi:10.1136/jclinpath-2020-2068.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThompson DM, Wang M. Splenic rupture in lymphoma: An uncommon but deadly complication. J Emerg Med. 2019;56(5):667-673. doi:10.1016/j.jemermed.2019.01.012.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDubey P, Le L. Spontaneous splenic rupture in non-Hodgkin lymphoma: Pathophysiology and management. Blood Cancer J. 2022;12(1):19. doi:10.1038/s41408-021-00591-x.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThompson AJ, Hoang MP. Management of traumatic and atraumatic splenic rupture: A review. J Clin Surg. 2021;89(3):120-126. doi:10.1097/JSU.0000000000000269.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Atraumatic splenic rupture, Diffuse large B-cell lymphoma, Non-Hodgkin lymphoma, Splenectomy, Hematologic malignancy, case report","lastPublishedDoi":"10.21203/rs.3.rs-7103532/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7103532/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eAtraumatic splenic rupture (ASR) is a rare but life-threatening clinical condition typically associated with hematologic malignancies. Among these, diffuse large B-cell lymphoma (DLBCL) is an aggressive subtype of non-Hodgkin lymphoma that commonly presents with lymphadenopathy or systemic symptoms. ASR as the initial presentation of DLBCL is exceedingly rare but represents a critical diagnostic and therapeutic challenge.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eWe report the case of a 61-year-old hispanic male with a history of hypertension and hyperlipidemia who presented with acute left upper-quadrant abdominal pain, hypotension, and symptoms of hypovolemic shock. He denied recent trauma but reported unintentional weight loss over six months. Physical exam revealed splenomegaly and localized tenderness. Laboratory studies showed anemia, elevated lactate, and leukocytosis. Contrast-enhanced CT imaging demonstrated massive splenomegaly, perisplenic hemorrhage, and parenchymal lacerations, consistent with spontaneous splenic rupture. The patient underwent emergent splenectomy and received extensive transfusion support. Histopathological analysis confirmed a diagnosis of DLBCL with high proliferative index. Staging PET scan revealed disseminated disease involving lymph nodes, liver, and bone marrow (Ann Arbor stage IV). Despite initiation of R-CHOP chemotherapy, the patient experienced rapid clinical decline and died six weeks after presentation.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eThis case highlights ASR as a rare and catastrophic initial presentation of DLBCL. Early recognition, rapid imaging, and surgical intervention are crucial to patient survival. However, the presence of disseminated disease and underlying tumor biology significantly affect prognosis. Clinicians should maintain high suspicion for ASR in lymphoma patients presenting with sudden abdominal pain and hemodynamic instability, even in the absence of trauma. Awareness of this rare presentation may enable earlier diagnosis and improve clinical outcomes.\u003c/p\u003e","manuscriptTitle":"Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 11:37:56","doi":"10.21203/rs.3.rs-7103532/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bc8002e2-7c0e-4bfc-8621-b9dc8c2f363f","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-27T09:24:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 11:37:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7103532","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7103532","identity":"rs-7103532","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}