Ji-Sun Han, et al. Ten days after the splenectomy, the patient was treated with an induction of chemotherapy using cytosine-arabi- noside (100 mg/m2, days 1-7) and idarubicin (12 mg/m2, days 1-3). He was subsequently treated with two cycles of consolidation chemotherapy using cytosine-arabinoside (3 g/m2, days 1-3) and idarubicin (12 mg/m2, days 1-2). The patient achieved complete remission, but then relapsed after 5 months. Reinduction chemotherapy using a FLAG- IDA regimen6 - fludarabine (30 mg/m2, days 1-5), cytosine- arabinoside (2 g/m2, days 1-7), and idarubicin (10 mg/m2, day 1-3) failed to induce remission. The patient was then treated with two more cycles of reinduction chemotherapy, but did not achieve complete remission. He was in a refrac- tory AML state and suffered from intra-abdominal abscess, abdominal pain, and severe hepatomegaly. Due to his low performance status, further chemotherapy could not be administered, and the patient was treated with supportive care. DISCUSSION A pathologic splenic rupture refers to rupture without trauma. A normal spleen does not rupture in the absence of trauma. Therefore, any “spontaneous” rupture should prompt a search by the clinician for any underlying splenic pathology.7 The majority of clinical symptoms of a splenic rupture include abdominal pain, abdominal tenderness and rigidity, hypotension, tachycardia, nausea and vomiting, dizziness, and syncope.1 The diagnosis of this condition is based on clinical signs and confirmatory diagnostic tests. Using ultrasonography or a CT and peritoneal aspirations of fresh blood may facilitate the diagnosis of apathological splenic rupture. CT imaging of the abdomen, although it is unsui- table for hemodynamically unstable patients, is currently the imaging method of choice. It is relatively rapid and accurate, and presents minimal risk to the patient.8 The exact etiology of a splenic rupture in hemotologic malignancies remains to be firmly established. The possible mechanisms suggested thus far include splenic enlarge- ment, leukemic blasts infiltration of the splenic capsule, splenic infarction resulting in capsular hemorrhage, and leukemia-associated coagulopathy.8 Male patients, patients above 20 years of age, patients displaying splenomegaly, and those who have recently undergone cytoreductive che- motherapy appear to be at higher risk of suffering a patho- logic rupture.1 Splenectomy is constituted the treatment of choice for adults with leukemia and a pathologic splenic rupture. Splenorrhaphy and partial splenectomy are generally thou- ght to play no role in the management of pathologic splenic ruptures in leukemia patients. Without surgical interven- tion, the mortality rate reported in this population appro- aches 100%.2 Therefore, early surgical intervention and appropriate hemoderivative support is most important. REFERENCES 1. Giagounidis AA, Burk M, Meckenstock G, Koch AJ, Schneider W. Pathologic rupture of the spleen in hematologic malignancies: two additional cases. Ann Hematol 1996;73:297-302. 2. Bernat S, García Boyero R, Guinot M, López F, Gozalbo T, Cãn igral G. Pathologic rupture of the spleen as the initial mani- festation in acute lymphoblastic leukemia. Haematologica 1998; 83:760-1. 3. Görg C, Barth P, Weide R, Schwerk WB. Spontaneous splenic rupture in acute myeloid leukemia: sonographic follow-up study. Bildgebung 1994;61:37-9. 4. Wong P, Takabayashi K, Sugiura Y, Asai T, Itoh K, Yoshida S, et al. Splenic rupture in acute megakaryoblastic leukemia. Jpn J Med 1987;26:234-6. 5. Rajagopal A, Ramasamy R, Martin J, Kumar P. Acute myeloid leukemia presenting as splenic rupture. J Assoc Physicians India 2002;50:1435-7. 6. Pastore D, Specchia G, Carluccio P, Liso A, Mestice A, Rizzi R, et al. FLAG-IDA in the treatment of refractory/relapsed acute myeloid leukemia: single-center experience. Ann Hematol 2003; 82:231-5. 7. Goddard SL, Chesney AE, Reis MD, Ghorab Z, Brzozowski M, Wright FC, et al. Pathological splenic rupture: a rare complication of chronic myelomonocytic leukemia. Am J Hematol 2007;82: 405-8. 8. Athale UH, Kaste SC, Bodner SM, Ribeiro RC. Splenic rupture in children with hematologic malignancies. Cancer 2000;88:480- 90. 140 Yonsei Med J http://www.eymj.org Volume 51 Number 1 January 2010