Delayed presentation of traumatic diaphragmatic injury and a spleno-pulmonary fistula with haemoptysis as only sign: A case report

Abstract

Background Injury to the spleen caused by blunt trauma is common and may be associated with traumatic diaphragmatic injury. We describe a unique presentation with haemoptysis due to complications of concurrent splenic and diaphragmatic injuries resulting in a spleno-pulmonary fistula. Case Report A healthy 37-year-old man presented with severe abdominal pain 3 days after blunt abdominal trauma. Contrast-enhanced computed tomography (CT) of the thorax and abdomen showed an American Association for the Surgery of Trauma grade 3 splenic injury with a large subcapsular haematoma, intraperitoneal blood and ongoing intraparenchymal extravasation managed by successful angioembolization of the proximal splenic artery. The patient returned to the emergency department 5 weeks later with a three–day history of progressively worsening haemoptysis. A new CT showed an increase in the splenic haematoma with protrusion into the thorax and a diaphragmatic rupture. Thoracotomy identified a spleno-pulmonary fistula – the splenic haematoma was evacuated, a non-anatomic lung resection was performed and the diaphragmatic defect closed. Cultures from the splenic haematoma grew Cutibacterium acnes which was treated with intravenous antibiotics. Conclusion We report a unique complication of concurrent splenic and diaphragmatic injury with the development of a spleno-pulmonary fistula possibly due to infection of the splenic haematoma at the time of angio-embolization of the spleen. This case shows the importance of diagnosing diaphragmatic injuries promptly, adhering to sterile technique and considering giving prophylactic antibiotics before angio-embolization.