Case Presentation: A 58-year-old female presented to the ED with one month of generalized worsening weakness, malaise, and diaphoresis. The patient’s medical history included severe Crohn’s disease, osteoporosis, tobacco use, and right kidney atrophy. Initial exam findings included abdominal distension, left upper quadrant tenderness, and anasarca. Labs revealed hemoglobin 8.6, hematocrit 25.0, WBC 10.7, platelet count 35K with elevated ESR, CRP and lactate dehydrogenase (LDH). Imaging revealed bilateral pleural effusions and a pericardial effusion. CT of the abdomen and pelvis revealed new interval splenic enlargement compared to three weeks prior. Overnight, the patient was found unresponsive in respiratory arrest requiring resuscitation and intubation. Upon ICU transfer, the patient was hypotensive and hypothermic with lab results revealing marked decreases in hemoglobin, hematocrit, platelets and haptoglobin with a negative Coombs test. A STAT CT revealed findings suspicious for a subcapsular splenic hematoma with significant lymphadenopathy throughout. The patient underwent emergency laparotomy with splenectomy with pathology revealing metastatic poorly differentiated adenocarcinoma of unclear origin with signet ring cell morphology and a non-specific immunohistochemical profile. The patient was discharged after stabilization but returned a few days later with worsening shortness of breath, jaundice and a CT revealing pancreatic mass with biliary obstruction. Initial concern was for pancreatic adenocarcinoma however after evaluation, oncology suspected small bowel or colon as the likely origin. Due to the patient’s hemodynamic instability and poor performance status, the patient was deemed inappropriate for chemotherapy during admission and transitioned to comfort measures. The patient’s cause of death was multi-organ failure secondary to stage IV metastatic adenocarcinoma of unknown origin three weeks after her initial presentation.

Discussion: Splenic hemorrhage secondary to metastatic adenocarcinoma is a rare yet well-documented complication that can occur late in the progression of diagnosed or undiagnosed cancer. Generally, metastasis to the spleen is an indication of advanced disease involving multiple other metastatic sites rather than primary malignancy. The most commonly reported primary sites of splenic metastases include choriocarcinoma (13.3%), melanoma (10%), and gastric carcinoma (6.7%), the latter being the suspected primary origin in our patient. Splenic metastasis is often asymptomatic in nature, but may present with discomfort in the left upper quadrant and symptoms related to pressure on other organs, such as early satiety, nausea and dyspnea.While spontaneous (non-traumatic) splenic hemorrhage as an initial presentation of malignancy is rare, it should be considered part of the differential diagnoses in middle aged and older adults. Spontaneous splenic rupture is also suggestive of the aggressive nature of the malignancy and likely adverse outcomes, however further research is needed to confirm. This case also highlights how a multidisciplinary approach is valuable in stabilizing and managing these critical patients.

Conclusions: Spontaneous splenic hemorrhage is an uncommon initial presentation of malignancy. Metastatic disease should be considered in patients with nonspecific symptoms and known risk factors.