A Rare Cause of Pneumoperitoneum

Ruptured splenic abscess as an extremely rare cause of pneumoperitoneum: A comprehensive review with a case report

“…Therefore, similar pathogens must be causative agents in our patient, however, unfortunately, the blood and abscess culture had negative results which may be ascribed to early high-dose antibiotic therapy administration or a technical error. The results of either blood or splenic abscess culture were as follows in reported cases: Positive for Klebsiella pneumoniae and anaerobe Prevotella intermedia in pus culture from the splenic abscess [3] , positive pus culture for Enterobacter cloacae [6] , positive pus culture for b-hemolytic Streptococcus, Escherichia coli ( E coli ), Morganella morganii , and Proteus mirabilis from the perisplenic fluid and positive blood culture for b-hemolytic Streptococcus [7] , positive abscess culture for Prevotella intermedia [8] , negative blood cultures for any growth of bacteria [9] , positive pus culture from abscess for E coli and negative blood culture [4] , positive abscess aspirate culture for peptostreptococcus species [10] , positive pus culture for E coli [11] . In addition, the spleen histopathology revealed infiltration of a moderate quantity of Gram-positive bacteria in 1 patient [12] and in 1 case, there was not any data regarding microbial culture [5] .…”

“…We presented a case that was afflicted by a splenic abscess whose rupture led to pneumoperitoneum. Based on a comprehensive review of the literature, we found only 10 case reports illustrating pneumoperitoneum following the rupture of a splenic abscess [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] . The search strategy used for the purpose of discovering these articles was the utilization of the keywords "Splenic Abscess" AND "Pneumoperitoneum" in the databases of PubMed, Scopus, and Google Scholar Advanced Search.…”

“…In the majority of these available cases (70%), an immunocompromised condition was notable. Diabetes mellitus in 4 [ [4] , [5] , [6] , 8 ] and human immunodeficiency virus (HIV) infection [7] , ulcerative colitis under treatment with immunosuppressive drugs and splenic hypoperfusion [10] , and malignancy (colon cancer and melanosarcoma) [12] in 1 patient were reported. In the 3 other cases, immunocompromised status was not cited in the patient's past medical histories [ 3 , 9 , 11 ].…”

“…Apart from typical symptoms of splenic abscess which are classically the triad of fever, left upper quadrant tenderness, and leukocytosis and were noticed in almost all patients in the early course of their disease, pneumoperitoneum following ruptured splenic abscess presents with acute abdomen in 80% of reported cases with signs of diffuse abdominal tenderness, rebound tenderness or involuntary muscle guarding of the abdomen [ [3] , [4] , [5] , [6] , [7] , [8] , 11 , 12 ]. Our patients did not manifest these symptoms and signs of peritonitis; we presume this observation owes to the very low amount of pneumoperitoneum and peritoneal pus which was not eligible enough to stimulate the peritoneum and if the medical and surgical interventions had been delayed in our case, the acute abdomen would have inevitably ensued.…”

“…The diagnostic approach was quite diverse among case reports. Chest X-rays for pneumoperitoneum and exploratory laparotomy to investigate the cause which showed splenic abscess rupture were utilized in 4 patients [ 3 , 5 , 10 , 11 ], abdominal CT scans for both pneumoperitoneum and ruptured splenic abscess in 2 patients [ 6 , 7 ], chest X-ray for pneumoperitoneum and abdominal CT for splenic abscess rupture in 2 patients [ 4 , 8 ], chest X-ray for pneumoperitoneum, abdominal CT firstly did not diagnose splenic abscess but exploratory laparotomy for splenic abscess rupture in 1 patient [9] , and abdominal X-ray for pneumoperitoneum and abdominal CT for ruptured splenic abscess in 1 patient [12] were employed. This diversity mainly owes to the clinical condition of the patient as when the patient was clinically stable, a more advanced imaging modality was used.…”