Sowers and Aubrey-Bassler Journal of Medical Case Reports 2011, 5:591 http://www.jmedicalcasereports.com/content/5/1/591 presentation while playfully wrestling with his partner. He did not present for assessment of the injury at that time. Splenectomy and post-operative recovery were uneventful and he was discharged home one week after presentation. The pathology report of our patient’s spleen later documented an organ weighing 235 grams and measuring 14.0 × 9.5 × 5.5 cm. This weight is within the reported range of normal [10]. Approximately 30% of the splenic parenchyma contained dilated hemorrhage filled vascular areas but the uninvolved par- enchyma appeared grossly and histologically normal. Discussion Delayed rupture of the spleen following significant trauma is relatively rare but is well documented in case reports, series and textbooks. A review of reported cases demonstrates that the vast majority of patients with nor- mal spleens ultimately diagnosed with delayed rupture sustained an injury of such significant magnitude that it required initial assessment in the emergency depart- ment. Previously described mechanisms have included automobile, motorcycle, or all terrain vehicle crashes, violent assaults or falls from a height (reviewed in [11]). Atraumatic ruptures of the spleen are also well described in spleens diseased by hematologic malig- nancy, parasitosis, infiltrates and in patients with impaired coagulation (reviewed in [3]). We present one of only a very few reported cases of delayed rupture of the normal spleen temporally associated with a trivial traumatic insult. The hallmark presentation of a patient with splenic rupture includes left upper quadrant pain, Kehr’s sign (shoulder pain secondary to diaphragmatic irritation by the hemoperitoneum) [1,2], as well as signs of general- ized peritonitis such as guarding and rebound tender- ness. Depending upon the severity and duration from onset to presentation, patients may also present with signs of hemodynamic compromise. Given this relatively nonspecific presentation there is often a wide differential diagnosis including much more common conditions such as appendicitis [1], acute coronary syndrome, gas- tric ulcer, renal colic and abdominal aortic aneurysm. Considering the difficulty in making the diagnosis of delayed splenic rupture, keen clinical suspicion on the part of the emergency room physician needs to be sup- ported with the appropriate use of various imaging modalities such as point- of-care ultrasound and com- puted tomography (CT). The accuracy of computed tomography (CT) for diagnosis of splenic injury is approximately 97% [2]. Thus, it is tempting to consider the use of abdominal computed tomography (CT) in a patient with unexplained abdominal pain even if they are hemodynamically stable, give no history of injury, Page 3 of 4 and have an unremarkable ultrasound. However, we are cognisant of the recent dramatic increase in computed tomography (CT) utilization and the potential hazards associated with it and thus would not make such a blan- ket recommendation. It is interesting to note that despite significant intra- abdominal blood loss and hypotension, our patient’s heart rate remained stable at < 90 bpm throughout his stay in our emergency department. Similarly, cases reported in the literature also describe relative bradycar- dia [2,12]. This phenomenon has previously been described and is likely explained by diaphragmatic and vagal nerve irritation by intra-abdominal blood [13]. In addition, both our patient and another reported in the literature [12] complained of gastro-esophageal reflux (GER) prior to presentation. We are unaware of a rela- tionship between GER and splenic rupture; however, it may be that the symptoms diagnosed as GER in these cases may actually have been attributable to an evolving splenic injury. Conclusion It seems more plausible that a non-diseased spleen should rupture as the result of some traumatic insult, even if temporally removed from the time of presenta- tion, than spontaneously. However, only a handful of cases potentially compatible with this explanation are reported in the literature, while a larger number of cases reported as spontaneous (and ostensibly meeting Orloff and Peskin’s criteria [4]) have been reported. The possi- bility remains that the association we have observed is not causal. However, given the non-specific symptoms associated with splenic rupture, the relatively high mor- tality rate and the effectiveness of early therapy it would be prudent to ask patients presenting with non-specific abdominal pain in detail about major and minor trauma in the preceding weeks. Eliciting such a history could lead to more timely diagnosis and therefore to a lower mortality rate. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Acknowledgements The authors wish to thank the patient for his cooperation and Dr. Chris Goodall, the attending emergency physician for this case. Author details 1Emergency Medicine, Dalhousie University, Halifax, NS, Canada. 2Primary Healthcare Research Unit, Memorial University of Newfoundland, St. John’s, NL, Canada.