Subcapsular splenic haematoma in a patient with sickle cell trait

Clinical History

A 19-year-old female patient with unremarkable past medical history presented to the emergency room complaining of left upper quadrant pain for the past 3 days. The patient recently travelled to Cusco located in the highlands of Peru at 3300 meters above the sea level.

Imaging Findings

The abdominal X-ray showed no abnormalities. The US revealed an enlarged spleen associated with well-defined hypoechoic, subcapsular mass of 5.3 x 2.9 x 5.2 cm located in the lower border of the spleen.

Contrast-enhanced CT showed splenomegaly, also a hypodense, homogeneous lesion with well-defined contour in the lower lateral region of the spleen characteristic of subcapsular haematoma associated with splenic lacerations. No abscess or active bleeding were seeing.
In the hospital the patient was treated conservatively. CT scan was repeated days later and revealed a decrease of the subcapsular haematoma. Based on these clinical history progression electrophoresis was performed and revealed the diagnosis of sickle cell trait.

Discussion

We presented a case of a young female without any significant past medical history that developed abdominal pain after a trip to a high altitude city. Sickle cell trait (SCT) should be in our differential diagnostic in a patient with this clinical history. SCT is present when a normal haemoglobin A gene from one parent and an abnormal sickle haemoglobin gene from the other are in the patient haemoglobin configuration. This characteristic is present in nearly 300 million people worldwide and nearly 8% of the African American population in the United States, being rare in Hispanics [1, 2]. Patients with SCT are generally asymptomatic but some conditions like hypoxia, dehydration, acidosis and hypothermia can produce clinical manifestation like renal papillary necrosis, haematuria, splenic infarction. SCT symptoms usually develop in a patient that do not know about their condition and never had any health problem [1, 3].

The cause of the splenic pathology is not well known but hypothesized that high altitude leads to hypoxic environment causing proliferation of Haemoglobin S and deformation of red blood cells leading to vaso-occlusion of the spleen [4]. High altitude exposure can cause splenic syndrome that starts with abdominal pain which is rapidly localized in the left hypochondrium [5].

The use of ultrasound and contrast-enhanced CT gives us valuable data for the diagnosis of subcapsular haematoma, splenic infarct, pseudocyst or rules out any other pathology. Also CT scans can be used to follow up the patient [6]. The suspicion of SCT should always be considered in a patient with this clinical history, to avoid unnecessary treatment like splenectomy. The treatment in these cases should be conservative with adequate hydration, supplemental oxygen and analgesics [7].

Differential Diagnosis List

Final Diagnosis

Subcapsular splenic haematoma in a patient with sickle cell trait.

URL:	https://www.eurorad.org/case/14501
DOI:	10.1594/EURORAD/CASE.14501
ISSN:	1563-4086