Sowers and Aubrey-Bassler Journal of Medical Case Reports 2011, 5:591 http://www.jmedicalcasereports.com/content/5/1/591 following trivial trauma reported in the literature in the last 60 years. In one case, the spleen was enlarged [5] and in the other, splenic size and weight were not reported [6]. Three other reports of delayed rupture fol- lowing such trauma published in the same time period did not include information on evidence of splenic dis- ease [7-9]. Given that the spleen was enlarged in the first case, not reported in the second case and that dis- ease information was not reported in the other three, the possibility remains that all of these represent rup- tures of diseased spleens, and that our case is the first report of delayed rupture of a normal spleen following trivial trauma. Given the dearth of publication in this area, the possibility remains that the associations observed in these reports are coincidental rather than causal. However, we feel that documenting these cases may lead to improved recognition of similar cases in the future and possibly to an enhanced understanding of the pathophysiology of splenic rupture. Case Presentation A 27-year-old Caucasian man presented to the emer- gency department (ED) following the acute onset of severe, sharp chest and abdominal pain radiating to his shoulder blades and testicles. These symptoms began acutely five hours earlier, waking him from sleep and were associated with nausea and generalized weakness. He was initially able to return to sleep although he clearly stated that the pain was exacerbated in the supine position. On presentation to the ED, his initial vital signs included a blood pressure of 80/60 mm Hg and a heart rate of 60 beats/minute described as ‘thready.’ His respiratory rate was 26 per minute and he was afebrile. His blood pressure while supine prior to fluid resuscitation was 98/60 mm Hg. The patient had a single episode of emesis in the ED. The initial abdom- inal examination demonstrated both guarding and rebound tenderness with normal bowel sounds but the remainder of the physical examination, including the testicles, was unremarkable. Fluid resuscitation was initiated and blood pressure stabilised at 110/60. His past medical history and review of systems were unremarkable including no peptic ulcer disease and no travel history. Family history did not include any bleed- ing diathesis, connective tissue or rheumatologic condi- tion. His only medication was ranitidine recently taken for heartburn as needed. Initial blood work demonstrated a hemoglobin level of 115 g/L without any obvious history of bleeding and a white blood cell count of 13.8 g/L. Liver enzymes, elec- trolytes, blood glucose, blood urea nitrogen, creatinine, and amylase were essentially normal, and an electrocar- diogram was unremarkable. Both the ED physician and consultant radiologist reported erect and supine views Page 2 of 4 of the abdomen and postero-anterior and lateral views of the chest were normal. In particular, no rib fractures were evident on the chest X-ray, and the left hemi-dia- phragm appeared normal. The point of care ultrasound machine was out-of-service at the time this patient presented. Intense pain persisted after a total of 20 mg of mor- phine, 50 mg of dimenhydrinate and 20 mg of hyoscine. He was sent for a contrast enhanced computed tomo- graphy (CT) scan of the chest, abdomen and pelvis which demonstrated a macerated spleen with rupture resulting in a significant hemoperitoneum (Figure 1). Only after this revelation and with repeated specific questioning did the patient recall an apparently trivial injury to his left side about one week prior to Figure 1 Coronal computed tomography image demonstrating macerated spleen, perisplenic hematoma and hemoperitoneum.