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Peliosis is a rare lesion characterized by widespread blood-filled cystic spaces, most often detected in the liver and the spleen. Spontaneous splenic rupture caused by splenic peliosis is often fatal. We report the case of a patient who underwent hemodialysis and received erythropoietin. The patient was admitted because of sudden onset of abdominal pain in the left side, and emergency laparotomy was performed. A ruptured enlarged spleen was found with a hematoma at the surface with 1600 mL of nonclotted blood in the peritoneal cavity. A splenectomy revealed an enlarged spleen weighing 500 g. Eleven days after admission, the patient recovered and was discharged from the hospital. This case report demonstrates that spontaneous splenic peliosis rupture needs to be considered in the differential diagnosis of chronic renal failure patients with abdominal pain in the left side who have been undergoing hemodialysis and receiving erythropoietin.