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Sforza C, Margelli M, Mourad F, Brindisino F, Heick JD, Maselli F. Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice. Physiother Theory Pract 2023; 39:641-649. [PMID: 35704038 DOI: 10.1080/09593985.2021.2021578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain. CASE DESCRIPTION This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living. DISCUSSION AND CONCLUSION The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.
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Affiliation(s)
- Carla Sforza
- Faculty of Medicine and Surgery, Department of Clinical Science and Translation Medicine, University of Rome "Tor Vergata", Roma, Italy.,Department of Physiotherapy, Sport Clinic Center, Firenze, Italy
| | - Michele Margelli
- Faculty of Medicine and Surgery, Department of Clinical Science and Translation Medicine, University of Rome "Tor Vergata", Roma, Italy.,Faculty of Medicine and Surgery, Department of Morphology Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy.,Department of Physiotherapy, Studio Andreotti-Margelli Terapika, Ferrara, Italy
| | - Firas Mourad
- Faculty of Medicine and Surgery, Department of Clinical Science and Translation Medicine, University of Rome "Tor Vergata", Roma, Italy.,Department of Physiotherapy, Lunex International University of Health, Exercise and Sports, Differdange, Luxembourg.,Luxembourg Health and Sport Sciences Research Institute A.s.b.l, Differdange, Luxembourg
| | - Fabrizio Brindisino
- Faculty of Medicine and Surgery, Department of Clinical Science and Translation Medicine, University of Rome "Tor Vergata", Roma, Italy.,Department of Medicine and Health Science "Vincenzo Tiberio," University of Molise C/o Cardarelli Hospital, ; Campobasso, Italy
| | - John D Heick
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, AZ, USA
| | - Filippo Maselli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (Dinogmi), University of Genova - Campus of Savona, Savona, Italy.,Sovrintendenza Sanitaria Regionale Puglia INAIL, ; Bari, Italy
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2
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Gafumbegete E, van der Weide BJ, Misgeld S, Schmidt H, Elsharkawy AE. Fatal Clostridium perfringens sepsis with spleen rupture and intraabdominal massive bleeding in a 37-week pregnancy. IDCases 2021; 26:e01355. [PMID: 34900590 PMCID: PMC8640441 DOI: 10.1016/j.idcr.2021.e01355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/27/2021] [Accepted: 11/28/2021] [Indexed: 11/27/2022] Open
Abstract
The maternal death rate remains unacceptably high worldwide, predominantly in areas of poor access to quality health services. According to the WHO, in 2017, 810 women died from preventable causes related to pregnancy and childbirth. Causes of maternal death are plenty, including previous morbidity and unexpected causes. Among the latter are infectious disease-related deaths. Herein, we describe a case of a 29-year-old woman at 37 weeks’ gestation who presented with right upper quadrant pain, which was initially considered to be pregnancy-related. However, she collapsed shortly after the hospital admission. The physical examination revealed severe hypovolemic shock due to a large amount of intraperitoneal free fluid. The patient was immediately rushed into an emergency cesarean section followed by exploratory laparotomy, which demonstrated a large intra-abdominal hemorrhage. The patient and her fetus died in the operating room. An autopsy revealed acute gangrenous cholecystitis along with abundant rod-shaped bacteria within the mucosa and vessels of the gallbladder, gas gangrene and rupture of the spleen, and signs of shock. Clostridium perfringens (CP) was isolated in the culture of a splenic sample. Although CP is a well-known and dreadful infectious etiological agent, catastrophic cases still happen. The acquaintance of this infection by the caregivers is crucial for the early diagnosis and treatment. This is a quite unique way to provide a dismal chance of survival in sepsis cases by this agent.
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Affiliation(s)
| | | | | | - Henning Schmidt
- General surgery department, Hümmling Hospital Sögel, Sögel, Germany
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3
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Bellantoni G, Guerrini F, Del Maestro M, Galzio R, Luzzi S. Simple schwannomatosis or an incomplete Coffin-Siris? Report of a particular case. eNeurologicalSci 2019; 14:31-33. [PMID: 30555950 PMCID: PMC6277249 DOI: 10.1016/j.ensci.2018.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/17/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Schwannomatosis is a genetic disorder that belongs to NF family. The mutation of SMARCB1 gene has been related to this entity and Coffin-Siris syndrome, as well. We reported a case of a female patient with SMARCB1 mutation who has developed a spontaneuous spleen rupture. CASE DESCRIPTION A 28 years old female patient with a story of a Sjogren syndrome, celiac disease and a surgically treated schwannoma, presented to our observation in July 2013 for a pain on the left elbow, where a tumefation was present. After neuroradiological evaluations, a surgical resection was performed and a schwannoma was diagnosed. Genetic exams revealed a puntiform SMARCB1 gene mutation. During 2015, she was subdued to the removal of an another schwannoma located into the cervical medullary canal. Few months later, she was operated in an another hospital for a spontaneous spleen rupture in a possible context of wandering spleen. CONCLUSION We think that the patient could suffer from a partially expressed Coffin-Siris syndrome. No cases of spontaneous rupture in a context of wandering spleen have been ever described as for as schwannomatosis or Coffin-Siris syndrome are concerned. More cases are necessary to establish a direct relationship.
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Affiliation(s)
- G. Bellantoni
- Unit of Neurosurgery, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - F. Guerrini
- Unit of Neurosurgery, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - M. Del Maestro
- Unit of Neurosurgery, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - R. Galzio
- Unit of Neurosurgery, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Italy
| | - S. Luzzi
- Unit of Neurosurgery, Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Italy
- Department of Emergency and Organ Transplantation, University “Aldo Moro”, Bari, Italy
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4
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Gurzu S, Bara T, Molnar C, Bara T, Butiurca V, Beres H, Savoji S, Jung I. The epithelial-mesenchymal transition induces aggressivity of mucinous cystic neoplasm of the pancreas with neuroendocrine component: An immunohistochemistry study. Pathol Res Pract 2019; 215:82-89. [PMID: 30391209 DOI: 10.1016/j.prp.2018.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/25/2018] [Accepted: 10/19/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic mucinous cystic neoplasms (MCN) are rare tumors that are usually diagnosed in females. MATERIALS AND METHODS In our department, only four of the 109 consecutive cases of pancreatic tumors (3.67%) were diagnosed as MCNs. In this report, we present the characteristics of these four specific cases which also showed unusual HER-2 positivity and neuroendocrine differentiation. RESULTS The four MCNs were diagnosed in patients with ages between 46 and 75 years. Other clinical particularities were the following: one benign case, splenic rupture as result of a giant cystic tumor on the tail of the pancreas directly invading the spleen in the second one, metastases in the accessory spleen in the third one and invasion of the abdominal vessels in the fourth case. In all of these cases, the ovarian-like stroma tested positivity for calretinin, progesterone receptor (PR) and, in cases 2 and 3, for AE1/AE3 keratin. The malignant tumor cells were marked by carcinoembryonic antigen, HER-2, maspin, PR and the neuroendocrine markers synaptophysin, CD56, and neuron-specific enolase. CONCLUSIONS These cases highlight the unusually aggressive behavior of pancreatic MCN with invasive carcinomas that share mixed exo- and endocrine components and show epithelial-mesenchymal transition.
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Affiliation(s)
- Simona Gurzu
- Department of Pathology, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania; Department of Pathology, CCAMF - Research Center, Targu Mures, Romania; Department of Pathology, Clinical County Emergency Hospital, Targu Mures, Romania.
| | - Tivadar Bara
- Department of Surgery, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Calin Molnar
- Department of Surgery, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Tivadar Bara
- Department of Surgery, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Vlad Butiurca
- Department of Surgery, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Hanga Beres
- Department of Pathology, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Simin Savoji
- Department of Pathology, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
| | - Ioan Jung
- Department of Pathology, University of Medicine, Pharmacy, Sciences and Technology, Targu Mures, Romania
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Elizalde-Torrent A, Val F, Azevedo ICC, Monteiro WM, Ferreira LCL, Fernández-Becerra C, Del Portillo HA, Lacerda MVG. Sudden spleen rupture in a Plasmodium vivax-infected patient undergoing malaria treatment. Malar J 2018; 17:79. [PMID: 29433507 PMCID: PMC5809972 DOI: 10.1186/s12936-018-2228-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/08/2018] [Indexed: 11/17/2022] Open
Abstract
Background Splenomegaly is one of the most common features of malaria. However, spontaneous splenic rupture, although unusual, represents a severe complication often leading to death. It is mostly seen in acute infection and primary attack, and it is most commonly associated with Plasmodium vivax. Here, a case of spontaneous splenic rupture diagnosed with a portable ultrasound apparatus shortly after starting treatment and with recurrent parasitaemia after splenectomy, is reported. Case description In November 2015, a 45-year-old Brazilian man presented to the hospital in Manaus with fever, headache and myalgia. He was diagnosed with P. vivax malaria and, after a normal G6PD test, he started treatment with chloroquine and primaquine and was discharged. Two days later, he went back to the hospital with abdominal pain, dyspnea, dry cough, pallor, oliguria and fever. Using a portable ultrasound, he was diagnosed of rupture of the spleen, which was removed by emergency surgery. After this episode, he suffered two more malaria episodes with high parasitaemia at approximately 2-month intervals. DNA from different portions of the spleen was extracted and a qualitative PCR was performed to detect P. vivax. Conclusions The splenic rupture suffered by this patient occurred 2 days after starting the treatment. Having a portable ultrasound apparatus may have saved the patient’s life, as it revealed a haemorrhage needing an urgent surgery. Parasites were detected by PCR in the extracted spleen. This patient suffered two more vivax malaria diagnosed episodes in spite of receiving and completing treatment with chloroquine and primaquine for each clinical attack. Splenic rupture during acute malaria is uncommon, but it is likely underdiagnosed and underreported, because the lack of means and equipment hinders diagnostic confirmation, especially in endemic areas.
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Affiliation(s)
| | - Fernando Val
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil.,Universidade do Estado do Amazonas (UEA), Manaus, Amazonas, Brazil
| | | | - Wuelton M Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil.,Universidade do Estado do Amazonas (UEA), Manaus, Amazonas, Brazil
| | - Luiz C L Ferreira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil
| | - Carmen Fernández-Becerra
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain
| | - Hernando A Del Portillo
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain. .,Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain. .,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain.
| | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil. .,Fundação Oswaldo Cruz, Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Manaus, Amazonas, Brazil.
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6
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Feola A, Niola M, Conti A, Delbon P, Graziano V, Paternoster M, Pietra BD. Iatrogenic splenic injury: review of the literature and medico-legal issues. Open Med (Wars) 2016; 11:307-315. [PMID: 28352813 PMCID: PMC5329846 DOI: 10.1515/med-2016-0059] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Iatrogenic splenic injury is a recognized complication in abdominal surgery. The aim of this paper is to understand the medico-legal issues of iatrogenic splenic injuries. We performed a literature review on PubMed and Scopus using iatrogenic splenic or spleen injury and iatrogenic splenic rupture as keywords. Iatrogenic splenic injury cases were identified. Most cases were related to colonoscopy, but we also identified cases related to upper gastrointestinal procedures, colonic surgery, ERCP, left nephrectomy and/or adrenalectomy, percutaneous nephrolithotomy, vascular operations involving the abdominal aorta, gynecological operation, left lung biopsy, chest drain, very rarely spinal surgery and even cardiopulmonary resuscitation. There are several surgical procedures that can lead to a splenic injury. However, from a medico-legal point of view, it is important to assess whether the cause can be attributed to a technical error of the operator rather than being an unpredictable and unpreventable complication. It is important for the medico-legal expert to have great knowledge on iatrogenic splenic injuries because it is important to evaluate every step of the first procedure performed, how a splenic injury is produced, and whether the correct treatment for the splenic injury was administered in a judgment.
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Affiliation(s)
- Alessandro Feola
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Massimo Niola
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Adelaide Conti
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Paola Delbon
- Department of Surgery, Radiology and Public Health, Public Health and Humanities Section, University of Brescia - Centre of Bioethics Research, Italy
| | - Vincenzo Graziano
- Department of Advanced Biome-dical Sciences, University of Naples “Federico II”, Naples, Italy
| | | | - Bruno Della Pietra
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
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Aleksic-Shihabi A, Jadrijevic E, Milekic N, Bulicic AR, Titlic M, Suljic E. Spontaneous Splenic Rupture Following Intravenous Thrombolysis with Alteplase Applied as Stroke Therapy - Case Report and Review of Literature. Med Arch 2016; 70:69-71. [PMID: 26980937 PMCID: PMC4779351 DOI: 10.5455/medarh.2016.70.69-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/28/2015] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Stroke is a medical emergency in neurology, and is one of the leading causes of death nowadays. At a recent time, a therapeutic method used in adequate conditions is thrombolysis, a treatment of an emerging clot in the brain vascular system by alteplase. The application of alteplase also has a high risk of life threatening conditions. CASE REPORT This is a brief report of a case with thrombolysis complication which manifested as a spleen rupture.
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Affiliation(s)
| | - Eni Jadrijevic
- Department of Neurology, University Hospital Center Split, Split, Croatia,Corresponding author: Eni Jadrijevic, MD. Department for Neurology, University Hospital Center Split, Split, Croatia. Phone: +385 21 556 599; Center Split, Split, Croatia. Phone: +385 21 556 599; ORCID ID: http://orcid.org/0000-0002-1002-938X. E-mail:
| | - Nina Milekic
- Department of Neurology, General Hospital Sibenik, Sibenik, Croatia
| | - Ana Repic Bulicic
- Department of Neurology, University Hospital Center Split, Split, Croatia
| | - Marina Titlic
- Department of Neurology, University Hospital Center Split, Split, Croatia
| | - Enra Suljic
- Department of Neurology, Sarajevo University Clinical Center, Sarajevo, Bosnia and Herzegovina
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Lessi F, Marson P, Colpo A, Marino F, Branca A, Tison T, Adami F. Spontaneous splenic rupture following stem cell mobilization with G-CSF and plerixafor in AL amyloidosis. Transfus Apher Sci 2015; 54:256-8. [PMID: 26458962 DOI: 10.1016/j.transci.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AL amyloidosis is a rare plasma cell dyscrasia with multiorgan involvement. Good risk patients are candidate to high dose chemotherapy and autologous stem cell transplantation. However both transplantation and stem cell collection entail significant risk in such patients. Plerixafor is a novel mobilizing agent approved for use in "poor mobilizer" patients with lymphoma and multiple myeloma; experience in systemic amyloidosis patients is limited. CASE REPORT We describe a case of spontaneous splenic rupture following administration of G-CSF and plerixafor in a patient with AL amyloidosis who previously underwent heart transplantation due to amyloid heart involvement. RESULTS AND CONCLUSION This is the first report of spontaneous splenic rupture following stem cell mobilization with G-CSF and plerixafor in AL amyloidosis. The role of plerixafor has to be established. AL amyloidosis patients undergoing stem cell mobilization need careful monitoring of signs and symptoms of spontaneous splenic rupture.
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Affiliation(s)
- Federica Lessi
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy.
| | - Piero Marson
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Anna Colpo
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Filippo Marino
- Pathology Unit, Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy
| | - Tiziana Tison
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Fausto Adami
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy
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Arcagök BC, Özdemir N, Tekin A, Özcan R, Eliçevik M, Şenyüz OF, Çam H, Celkan T. Spontaneous splenic rupture in a patient with congenital afibrinogenemia. Turk Arch Pediatr 2014; 49:247-9. [PMID: 26078670 DOI: 10.5152/tpa.2014.1070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 12/14/2012] [Indexed: 11/22/2022]
Abstract
Afibrinogenemia is a rare bleeding disorder which is observed with an incidence of 1:1 000 000. It is an autosomal recessive disease and occurs as a result of mutation in one of the three genes which code the three polypeptide chains of fibrinogen. Basic clinical findings include spontaneous bleeding, bleeding after minor trauma or due to surgery. Splenic rupture in afibrinogenemia has been reported only in 6 cases so far. In this article, we present a 15-year old congenital afibrinogenemia patient with spontaneous splenic rupture.
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Affiliation(s)
- Baran Cengiz Arcagök
- Department of Pediatrics, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Nihal Özdemir
- Department of Pediatrics, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Ayşe Tekin
- Department of Pediatrics, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Rahşan Özcan
- Department of Pediatric Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Mehmet Eliçevik
- Department of Pediatric Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Osman Faruk Şenyüz
- Department of Pediatric Surgery, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Halit Çam
- Department of Pediatrics, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Tiraje Celkan
- Department of Pediatrics, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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