Atraumatic splenic rupture (ASR) accounts for just over 3% of all cases of splenic rupture and is associated with a high mortality rate. The most common culprit is acute infection with Epstein-Barr virus (EBV) but other documented aetiologies include neoplasia, other viral/bacterial infections, acute and chronic pancreatitis, amyloidosis and anticoagulant medications. There are four previous reports of cocaine-associated ASR but never before has it been documented in combination with concurrent acute EBV infection.

A 21-year-old man presented to hospital with acute left shoulder pain which radiated to the right shoulder and upper abdomen. He denied any history of recent trauma and had no relevant past medical history. He took no regular prescription medications but had used cocaine within the previous 24 h. Investigations revealed splenomegaly, a Grade 3 subcapsular splenic haematoma, moderate haemoperitoneum and an incidental 9 mm splenic artery pseudoaneurysm. There was also serological evidence of acute EBV infection. Prophylactic endovascular embolisation of the pseudoaneurysm was performed and the splenic rupture was managed non-operatively. The patient remained admitted in hospital for seven days and did not require any transfusion of blood products. Serial imaging showed complete resolution of the haemoperitoneum after 5 wk. The importance of abstinence from illicit drug use was emphasised to the patient but it is unknown whether or not he remains compliant.

This case demonstrates that ASR is a rare condition that can result from acute EBV infection and cocaine ingestion and requires a high index of suspicion to diagnose clinically.

• Atraumatic
• Spontaneous
• Splenic rupture
• Cocaine
• Epstein-Barr virus
• Splenic artery pseudoaneurysm
• Case report