Case Report: Non-traumatic splenic rupture as the first presentation of diffuse large B-cell lymphoma complicated by clinically diagnosed pulmonary aspergillosis supported by metagenomic next-generation sequencing.

Non-traumatic splenic rupture is an uncommon, life-threatening event and may be the first sign of an unrecognized hematological malignancy. We describe a 60-year-old man who presented with hemorrhagic shock due to splenic rupture. Emergency splenectomy controlled the bleeding and provided the diagnostic specimen. Histology supported diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS), with a non-germinal-center B-cell phenotype by the Hans algorithm and a Ki-67 index of approximately 90%. Epstein-Barr virus-encoded RNA was negative. Because fluorescence in situ hybridization for MYC, BCL2, and BCL6 rearrangements was unavailable, high-grade B-cell lymphoma with rearrangements could not be excluded. Staging was incomplete; the case is therefore described as DLBCL with dominant splenic presentation rather than primary splenic DLBCL. The post-operative course was complicated by severe pneumonia. Pulmonary aspergillosis was clinically diagnosed based on the overall host profile, bronchoscopic findings, serum galactomannan positivity, BALF mNGS results, and subsequent culture. BALF mNGS detected Aspergillus fumigatus and Pseudomonas aeruginosa before culture confirmation. Voriconazole was started, but the patient died on post-operative day 11, about 24 h later. Splenic rupture was therefore the first manifestation of DLBCL, and BALF mNGS served as supportive, rather than standalone, evidence for pulmonary aspergillosis in a critically ill immunocompromised patient.