the incidence of splenic abscess is a clinically uncommon disease with current literature reporting a 0.140.7% occurrence rate [ 1 , 2 ] .
although splenic abscesses are a clinical rarity , they have the potential to be fatal .
the presentation of this disease is often vague and insidious including left upper quadrant abdominal pain , fever and chills .
additionally , these patients may present with leukocytosis , left upper quadrant mass and pleural effusion on chest x - ray .
splenic abscesses generally occur in patients with underlying comorbidities , which commonly include neoplasia , immunodeficiency , trauma , metastatic infection , splenic infarct or diabetes .
the best management of splenic abscesses is still debatable with the various modalities including antibiotics , percutaneous drainage or splenectomy .
the current literature supports a 67100% success rate with percutaneous drainage ; however , tung et al .  
states that the most optimal treatment for splenic abscess is splenectomy . of the 600 cases of splenic abscess documented in the current literature ,
most have been described as air confined to the left upper quadrant on chest x - ray .
we report a young patient with a ruptured splenic abscess resulting in an acute abdomen and pneumoperitoneum . to our knowledge
, there have only been four other reported cases of ruptured splenic abscess causing pneumoperitoneum [ 3 , 4 ] .
a 48-year - old female with the past medical history of diabetes , coronary artery disease and psoriasis , presented with acute onset of diffuse abdominal pain 2 days prior to admission to the hospital . upon presentation , she was tachycardic with a heart rate of 130 and hypotensive with a blood pressure of 78/45 .
she was resuscitated in the emergency department with intravenous fluids and her blood pressure and heart rate responded appropriately .
her initial labs showed a normal wbc level of 8.3 thou / mcl ; however , the patient was acidotic with a ph of 7.29 and a lactic acid level of 3.5 mmol / l .
an acute abdominal series was obtained demonstrating free air below the right hemidiaphragm ( fig .  1 ) .
the patient was subsequently boarded for an exploratory laparotomy with repair of perforated viscus , as that is the usual cause of pneumoperitoneum , especially under the right hemidiaphragm .
because the patient 's vital signs stabilized after being resuscitated , the decision was made to obtain a ct scan to better assess the location of the perforated viscus .
much to our surprise , the patient did not have a perforated viscus , but a splenic abscess that had ruptured causing the pneumoperitoneum ( fig .  2 ) . 

figure  2:ct scan demonstrating gas - forming splenic abscess and free air in the peritoneal cavity .
ct scan demonstrating gas - forming splenic abscess and free air in the peritoneal cavity .
the patient then became increasingly confused and her vital signs again deteriorated demonstrating worsening sepsis .
the patient was taken to the operating room where a laparoscopic splenectomy was attempted but was quickly converted to laparotomy with splenectomy due to the gross contamination of the abdomen .
the patient was continued on antibiotics and taken to the intensive care unit for post - operative care .
the splenic abscess grew prevotella intermedia , a bacterium commonly found in the oral flora .
the patient underwent a full work - up looking for the source of the splenic abscess .
a transesophageal echocardiogram was performed but was negative for any masses , thrombus or vegetation .
furthermore , a panorex was performed and was negative as the patient had reported tooth pain 1 week prior to her admission .
she returned to the clinic on post - operative day 14 to receive her splenectomy vaccinations .
although a rare disease , splenic abscess should be included on the differential diagnosis of a patient presenting to the hospital with peritonitis or pneumoperitoneum .
this is especially true for patients who are immunocompromised or have underlying comorbidities including neoplasia , diabetes , trauma or history of splenic infarct or embolization . in our case ,
ct scan provided important information about the cause of our patient 's pneumoperitoneum , as we had assumed it was due to a perforated ulcer or diverticulitis .
this did change our operative management , as we attempted to perform a less invasive surgery on our patient by starting with a laparoscopic technique .
however , we had to convert to an open splenectomy due to the gross contamination and adhesions from the splenic abscess .
in retrospect , an open laparotomy was the best approach to this patient 's care as it allowed for better visualization and irrigation of the abdominal cavity .
it is unknown if we had successfully performed the splenectomy laparoscopically if it would have decreased recovery time .
the current literature supports the laparoscopic splenectomy as a safe and effective procedure in patients with splenic abscess demonstrating an average length of stay of 14 days . in our case ,
the patient remained in the hospital for only 10 days after converting to the open procedure .
the current literature reports that the most common organisms found in splenic abscesses are aerobic microbes , particularly streptococci and escherichia coli .
this microbe is commonly found in the oral flora and is associated with periodontal disease .
although our transesophageal echocardiogram and panorex were both negative , we believe this splenic abscess developed as a result of translocation of the oral flora as the patient was complaining of a tooth ache 1 week prior to her presentation . in summary , we have presented a case of ruptured splenic abscess as a cause of pneumoperitoneum and peritonitis .
although rare , we encourage splenic abscess be included on the differential diagnosis of patients presenting with peritonitis and pneumoperitoneum .
although there is still controversy in the current literature when managing splenic abscesses , our recommendation is splenectomy , especially in the case of ruptured splenic abscess resulting in hemodynamic instability . whether it is better to perform the splenectomy laparoscopically or open is still debatable , the important thing is to obtain source control .
furthermore , a full work - up is required for patients presenting with a splenic abscess as the underlying cause could cause more serious illnesses for the patient in the future .
there are no conflicts of interests or financial funding to disclose for any of the contributing authors .
 we encountered a case of ruptured splenic abscess presenting as peritonitis and pneumoperitoneum . 
 our patient did not have an underlying neoplasm nor was she immunosuppressed . in our case , 
 splenectomy was the treatment of choice in combination with antibiotics , which proved to be a good outcome for the patient . 
 work - up for the cause of the abscess was negative , although bacteria predominately found in the oral flora were isolated from the abscess . 
 we strongly encourage that splenic abscess be considered on the differential diagnosis of patients presenting with pneumoperitoneum and peritonitis , although a clinical rarity . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST