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 .