Atraumatic Splenic Rupture as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review

Background: Atraumatic splenic rupture (ASR) is a rare but life-threatening clinical condition typically associated with hematologic malignancies. Among these, diffuse large B-cell lymphoma (DLBCL) is an aggressive subtype of non-Hodgkin lymphoma that commonly presents with lymphadenopathy or systemic symptoms. ASR as the initial presentation of DLBCL is exceedingly rare but represents a critical diagnostic and therapeutic challenge. Case Presentation: We report the case of a 61-year-old hispanic male with a history of hypertension and hyperlipidemia who presented with acute left upper-quadrant abdominal pain, hypotension, and symptoms of hypovolemic shock. He denied recent trauma but reported unintentional weight loss over six months. Physical exam revealed splenomegaly and localized tenderness. Laboratory studies showed anemia, elevated lactate, and leukocytosis. Contrast-enhanced CT imaging demonstrated massive splenomegaly, perisplenic hemorrhage, and parenchymal lacerations, consistent with spontaneous splenic rupture. The patient underwent emergent splenectomy and received extensive transfusion support. Histopathological analysis confirmed a diagnosis of DLBCL with high proliferative index. Staging PET scan revealed disseminated disease involving lymph nodes, liver, and bone marrow (Ann Arbor stage IV). Despite initiation of R-CHOP chemotherapy, the patient experienced rapid clinical decline and died six weeks after presentation. Conclusions: This case highlights ASR as a rare and catastrophic initial presentation of DLBCL. Early recognition, rapid imaging, and surgical intervention are crucial to patient survival. However, the presence of disseminated disease and underlying tumor biology significantly affect prognosis. Clinicians should maintain high suspicion for ASR in lymphoma patients presenting with sudden abdominal pain and hemodynamic instability, even in the absence of trauma. Awareness of this rare presentation may enable earlier diagnosis and improve clinical outcomes.