Delayed splenic rupture as a cause of haemoperitoneum in a CAPD patient with amyloidosis.

Case. A 59-year-old woman was maintained on peritoneal dialysis for end-stage renal failure due to primary amyloidosis complicated by acute crescentic glomerulonephritis. She had suffered no previous complications related to peritoneal dialysis. She had a minor fall down two stairs and attended the casualty department on the following day with right hip pain. Her peritoneal dialysis fluid was clear. No serious injuries were detected and she was discharged. Four days later she was admitted acutely with confusion and generalized abdominal and left-sided chest pain. She was shocked with a blood pressure of 70u45 mmHg, pulse rate of 115. Full blood count revealed a haemoglobin level of 7.2 gudl (previously 11 gudl). The peritoneal dialysate was heavily bloodstained suggesting intra-peritoneal haemorrhage. Microscopy of the peritoneal fluid revealed 3310 white cells and 12 195310 red cells per litre. No organisms were seen and subsequent culture was sterile. CT scan of the abdomen revealed an enlarged spleen with intrasplenic haematoma. The splenic capsule had ruptured, resulting in a profound intra-peritoneal bleed. The patient was resuscitated and underwent emergency splenectomy but died of numerous infective complications 6 weeks later. The removed spleen was enlarged and focally haemorrhagic. The capsule was lacerated, and partially enveloped underlying haematoma. Microscopic examination of the specimen confirmed the presence of amyloid deposition within the splenic substance. It appeared that our patient had suffered minor trauma to an abnormal, amyloid infiltrated spleen, resulting in a subcapsular bleed. The clinical presentation was delayed until the splenic capsule ruptured.