PMC4086625_01
Computed tomography (CT) imaging of the abdomen and pelvis showing (A) spleen at presentation, (B) spleen showing infarction, day 1 and (C, D) horizontal and coronal views of the ruptured spleen, day 2. (E, F) Pathologic specimens. (E) The diagnostic bone marrow aspirate (top, Diff-Quick x 40) and corresponding biopsy (bottom, hematoxylin and eosin [H & E] x 40) showing sheets of blasts with high nuclear cytoplasmic ratio, fine chromatin and prominent nucleoli. A subset of the cells show more abundant gray cytoplasm and convoluted nuclei consistent with monocytic features. (F) Spleen with pool of blood consistent with rupture (arrowhead) and apoptotic white pulp (arrow) and congested red pulp (top, H & E x 4) and a higher magnification with arrow indicating white pulp apoptosis involving the left portion of a Malpighian body (bottom, H & E x 20). The spleen was not involved by leukemia. Th is was confirmed by negative immunohistochemical marking for CD34.
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F1
The bone marrow (BM) was markedly hypercellular and replaced with blasts with minimal residual hematopoiesis (Figure 1). Computed tomography (CT) imaging revealed borderline splenomegaly by radiographic criteria (Figure 1), but no other abnormalities. Additionally, an incidental new finding of a 3 x 2.6 cm rounded hypodensity in the anterior part of the spleen consistent with a splenic infarct was noted (Figure 1). After initial clinical stabilization with aggressive blood product transfusions and hemodynamic support, a CT scan demonstrated a massive hemoperitoneum with a sentinel clot present in the left upper quadrant, implicating SSR as the cause of the bleed (Figure 1). Pathologic examination of the resected ruptured spleen showed no evidence of leukemia (Figure 1).