Spontaneous Splenic Rupture Associated With Cytomegalovirus Infection: A Case Report

Atraumatic splenic rupture is a rare but potentially life-threatening condition, most commonly associated with infectious, hematological, neoplastic, inflammatory, or iatrogenic disorders. Cytomegalovirus (CMV)-associated splenic rupture is an exceptionally uncommon complication in immunocompetent individuals. We report the case of a 46-year-old immunocompetent man who presented to the emergency department with acute abdominal pain and a low-grade fever. Laboratory investigations revealed mild microcytic anemia, thrombocytopenia, elevated inflammatory markers, and mild transaminase elevation. Contrast-enhanced abdominal computed tomography demonstrated splenomegaly, a large perisplenic collection consistent with a subcapsular hematoma, and moderate hemoperitoneum, raising suspicion of atraumatic splenic rupture. During clinical observation, the patient developed hemodynamic instability, prompting emergency exploratory laparotomy. Intraoperative findings included massive hemoperitoneum, capsular laceration involving the upper pole, and an extensive subcapsular hematoma. Splenectomy was performed. Postoperative serological investigations revealed markedly elevated anti-CMV IgM levels associated with low anti-CMV IgG levels and low IgG avidity, consistent with acute CMV infection. The pathological examination supported the diagnosis of CMV-associated atraumatic splenic rupture. No antiviral therapy was deemed necessary following infectious disease consultation, and the patient recovered uneventfully with planned post-splenectomy vaccination. CMV infection has increasingly been linked to thrombotic and vascular complications, even in immunocompetent individuals. Proposed mechanisms of splenic rupture include endothelial dysfunction, transient prothrombotic states, lymphocytic infiltration of splenic tissue, ischemic injury, and reduced capsular elasticity. Since clinical manifestations are often nonspecific and may mimic other causes of acute abdomen, diagnosis can be challenging. Contrast-enhanced computed tomography remains the gold standard for diagnosis and therapeutic planning. Management depends on the severity of splenic injury and the patient's hemodynamic status; however, splenectomy remains the preferred treatment in cases of severe injury or hemodynamic deterioration. This case highlights the importance of considering CMV infection in the differential diagnosis of atraumatic splenic rupture and underscores the value of early imaging and prompt intervention in optimizing patient outcomes.