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Splenic Infarction

Splenic infarction, defined as ischemia of the spleen due to diminished vascular supply, is a clinical entity that may develop in various hematological, thrombotic, infectious, and neoplastic diseases. Upper left quadrant abdominal pain is the main symptom, but the clinical presentation can be delayed or even absent in the initial stages. A thorough clinical examination and imaging studies, such as ultrasonography and computed tomography, are key elements of the workup.


Presentation

Necrosis and ischemia of splenic parenchyma occurring on the grounds of impaired arterial blood supply to this organ are termed splenic infarction and numerous conditions have been described as underlying causes [1]. Infections (malaria, brucellosis, bacterial endocarditis, infectious mononucleosis, sepsis), hematologic disorders (sickle cell disease, thrombophilia, and most importantly, thromboembolic states), malignant tumors, and a range of miscellaneous conditions (antiphospholipid syndrome, pancreatic disease, and intrinsic splenic blood vessel malformations) are some of the most commonly reported etiologies [1] [2] [3] [4] [5]. The main presenting feature of a splenic infarction is abdominal pain, typically situated in the upper left quadrant [1] [4] [6] [7]. As a result of irritation of the diaphragm, the pain can project to the left shoulder (known as Kehr's sign) and can be flank, whereas diffuse abdominal pain and pleuritic chest pain have also been reported [1] [3] [6] [7]. Nausea, vomiting, fever, and chills are frequent accompanying complaints [1] [3] [6] [7]. Furthermore, constitutional symptoms (fatigue, malaise) and a poor general condition might lead to a state of shock due to severe subcapsular bleeding that may be life-threatening [1] [5]. In a significant number of cases, patients are often asymptomatic in the initial stages, especially those presenting with hematologic disorders as the underlying cause [3] [7].

Splenomegaly
  • On admission, he had a low-grade fever and was grossly anaemic; examination revealed splenomegaly. An ultrasound scan confirmed splenomegaly with areas of splenic infarction. Subsequent tests suggested possible Epstein-Barr virus infection.[ncbi.nlm.nih.gov]
  • Physical examination on admission revealed a palpable splenomegaly.[ncbi.nlm.nih.gov]
  • Splenic infarction with splenomegaly is a catastrophic complication usually requiring splenectomy.[ncbi.nlm.nih.gov]
  • This small case series suggests that if a patient with malaria is complaining of left upper quadrant abdominal pain, pleuritic left lower chest pain and/or enlarging tender splenomegaly during treatment, splenic infarct should be suspected and managed[ncbi.nlm.nih.gov]
  • RESULTS: Most patients presented with fever, left upper quadrant pain and/or splenomegaly, but no specific symptoms or signs appear to predict underlying infarction.[ncbi.nlm.nih.gov]
Fever
  • Recent data suggest that antiphospholipid antibodies may be responsible for certain clinical manifestations of acute Q fever.[ncbi.nlm.nih.gov]
  • Azithromycin was promptly given, but her fever and abdominal pain persisted. A strong suspicion of mononucleosis led to serological tests for EBV and CMV, which confirmed coinfection of EBV and CMV.[ncbi.nlm.nih.gov]
  • Only half the subjects complained of localized left-sided abdominal pain, 36% had left-sided abdominal tenderness; 31% had no signs or symptoms localized to the splenic area, 36% had fever, 56% had leukocytosis and 71% had elevated lactate dehydrogenase[ncbi.nlm.nih.gov]
  • Symptoms were present in 69 per cent of the patients and included abdominal pain, fever and chills, and constitutional symptoms; 18 patients were asymptomatic.[ncbi.nlm.nih.gov]
  • CMV manifestations can cover a broad spectrum from fever to as severe as pancytopenia, hepatitis, retinitis, meningoencephalitis, Guillain-Barre syndrome, pneumonia, and thrombosis.[ncbi.nlm.nih.gov]
Gaucher Disease
  • These diseases include chronic myelogenous leukemia, myelofibrosis, Gaucher disease, Malarial splenomegaly syndrome, AIDS with mycobacterium avium complex, Lymphoma. Rarely, abnormal splenic vascular anatomy may cause infarction.[ncbi.nlm.nih.gov]
  • Other causes of splenomegaly (for example, Gaucher disease or hemoglobinopathies ) can also predispose to infarction. Splenic infarction can also result from a sickle cell crisis in patients with sickle cell anemia.[en.wikipedia.org]
  • Other less common causes include infectious mononucleosis, sickle cell disease, Gaucher disease, wandering spleen, sepsis, pancreatitis, infiltrative diseases, and collagen-vascular diseases [ 3 ].[karger.com]
Malaise
  • Furthermore, constitutional symptoms (fatigue, malaise) and a poor general condition might lead to a state of shock due to severe subcapsular bleeding that may be life-threatening.[symptoma.com]
  • Most patients with symptoms present 1–6 weeks after a bite from an infected tick with malaise, fatigue, myalgia, and anorexia, followed by nausea, vomiting, fever, and shaking chills [ 2 , 3 , 6 ].[doi.org]
Abdominal Pain
  • A 19-year-old woman presented with severe upper abdominal pain for 5 hours as well as flu-like symptoms and jaundice for 2 to 3 weeks.[ncbi.nlm.nih.gov]
  • BACKGROUND: The evaluation of a febrile patient with acute abdominal pain represents a frequent yet possibly challenging situation in the emergency department (ED).[ncbi.nlm.nih.gov]
  • The main presenting feature of a splenic infarction is abdominal pain, typically situated in the upper left quadrant.[symptoma.com]
  • Chronic mesenteric ischaemia is an important cause of abdominal pain, especially in older patients with risk factors for vascular disease.[ncbi.nlm.nih.gov]
  • Evaluation Abdominal pain remains the leading chief complaint in patients diagnosed with a splenic infarct. Evaluation of patients who present with abdominal pain requires a broad differential approach.[ncbi.nlm.nih.gov]
Left Upper Quadrant Pain
  • Splenic infarction is a common cause of left upper quadrant pain and must be suspected in patients with hematologic or thromboembolic conditions and signs of localized or systemic inflammation.[ncbi.nlm.nih.gov]
  • The left upper quadrant pain resolved after 8 days and the patient remains asymptomatic 2 years post-procedure.[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 17-y-old boy diagnosed with infectious mononucleosis due to Epstein-Barr virus infection who complained of left upper quadrant pain. A magnetic resonance imaging scan showed a splenic infarct in the enlarged spleen.[ncbi.nlm.nih.gov]
  • RESULTS: Most patients presented with fever, left upper quadrant pain and/or splenomegaly, but no specific symptoms or signs appear to predict underlying infarction.[ncbi.nlm.nih.gov]
  • Thus, in peritoneal dialysis patients with diffuse atherosclerosis or the risk of systemic embolization, symptoms of unexplained left upper quadrant pain and culture-negative peritonitis should be evaluated to rule out splenic infarction.[ncbi.nlm.nih.gov]
Acute Abdomen
  • It is usually asymptomatic but can present with an acute abdomen when associated with torsion. Most authors advocate surgical treatment.[ncbi.nlm.nih.gov]
  • Fever and chills develop in some cases. [3] It has to be differentiated from other causes of acute abdomen.[en.wikipedia.org]
  • It has to be differentiated from other causes of acute abdomen. An abdominal CT scan is the most commonly used modality to confirm the diagnosis, although abdominal ultrasound can also contribute.[definitions.net]
  • Differential Diagnosis As with many cases of acute abdomen, there is a wide range of differentials to consider, narrowed down through clinical features and investigations.[teachmesurgery.com]
Severe Abdominal Pain
  • On day 4 of admission, the patient complained of severe abdominal pain. Abdominal computed tomography scanning revealed findings of splenic infarction. Two months after the occurrence of splenic infarction, a splenectomy was performed.[ncbi.nlm.nih.gov]
  • On day 4 of admission, the patient complained of severe abdominal pain. Abdominal computed tomography scanning revealed findings of splenic infarction.Two months after the occurrence of splenic infarction, a splenectomy was performed.[doi.org]
Right Upper Quadrant Pain
  • This lesion was identified 1 day after the first presentation of peri-umbilical and right upper quadrant pain. She had abnormal hepatic function and mild splenomegaly, and was diagnosed as having primary Epstein-Barr virus (EBV) infection.[ncbi.nlm.nih.gov]
Tachycardia
  • The clinical picture associated with splenic infarction is typically nonspecific; manifestations may include fever, tachycardia, and left-upper-quadrant tenderness.[ncbi.nlm.nih.gov]
  • Examination findings included resting tachycardia and melenic stool. Blood pressure was 95/50 mm Hg. Multiple raised, soft, bluish 0.3 to 1 cm lesions were noted on the trunk and extremities.[consultant360.com]
  • Chest examination was clear and the cardiac examination did not show any tachycardia, murmur, gallop or rub.[em-consulte.com]
Alopecia
  • As the clinical use of sorafenib increases, many adverse effects have been reported, such as hand-foot skin reaction, diarrhea, anorexia, asthenia, alopecia, weight loss, hypertension and arterial thromboembolism.[ncbi.nlm.nih.gov]
Left Shoulder Pain
  • Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign). Septic thromboemboli may result in splenic abscesses, which present with sepsis and left upper abdominal pain.[thehealthscience.com]

Workup

The diagnosis of a splenic infarction can be made through a detailed clinical and imaging workup. Firstly, patients should be asked about the development of symptoms, their progression, as well as duration, since reports show that abdominal pain may last up to a week before the initial examination [1]. Secondly, a detailed personal history encompassing preexisting neoplastic, prothrombotic, or hematologic disorders that could predispose the patient to ischemic events is also a vital component of the workup. The role of a properly conducted physical examination is even more important, as abdominal tenderness (particularly in the upper left quadrant), referred shoulder pain (Kehr's sign), and possibly splenomegaly can be detected [1] [3]. Imaging studies, however, are pivotal when a presumptive diagnosis is made. Ultrasonography is one of the first methods that should be employed [3], and the presence of wedge-shaped lesions exhibiting a hypoechoic pattern is highly suggestive of an acute splenic infarction [8]. Because ultrasonography does not pose a high rate of diagnosis (ranging from 18%-63% in isolated case series) [3] [6], computed tomography (CT) and magnetic resonance imaging (MRI) are superior studies that are recommended for the assessment of the spleen [1] [2]. The use of contrast is favored for both studies (iodine for CT and gadolinium for MRI), and the previously mentioned wedge-shaped lesions are typically seen using both methods in the periphery of the organ (hypoechoic on CT and abnormal signal intensity on MRI, respectively) [1] [2] [8]. If the spleen is completely affected by ischemia, a diffuse hypodense appearance is observed [8].

Thrombocytosis
  • Changes in the blood count included anemia (53%), leukocytosis (49%), and thrombocytosis (7%). Liver-spleen scans were diagnostic in 90% of patients and computerized tomography identified the infarct in 75%.[ncbi.nlm.nih.gov]
  • Hayag-Barin JE, Smith RE, Tucker FC Jr (1998) Hereditary spherocytosis, thrombocytosis, and chronic pulmonary emboli: a case report and review of the literature.[doi.org]
Hyperviscosity
  • Abstract Polycythaemia vera is associated with thrombotic phenomenon due to hyperviscosity of blood. Splenic infarction with splenomegaly is a catastrophic complication usually requiring splenectomy.[ncbi.nlm.nih.gov]

Treatment

  • In addition, splenic abscess must be suspected in patients of splenic infarction, especially if the infectious signs persist despite appropriate treatment. Rapid diagnosis and treatment are essential as its course can prove fatal.[ncbi.nlm.nih.gov]
  • In addition, splenic abscess must be suspected in patients with splenic infarction, especially if the infectious signs persist despite appropriate treatment. Rapid diagnosis and treatment are essential as its course can prove fatal.[ncbi.nlm.nih.gov]
  • Clinicians must be aware that left hypochondrial pain occurring during treatment for acute malaria may be due to splenic infarction.[ncbi.nlm.nih.gov]
  • We report a patient who developed spontaneous splenic infarction after the use of sumatriptan for the treatment of migraine headache.[ncbi.nlm.nih.gov]
  • We report a patient who developed spontaneous splenic infarction after the use of sumatriptan for the treatment of migraine headache. Key words[doi.org]

Prognosis

  • They occur in elderly men and are associated with a very poor prognosis. CASE REPORT: We report a case of advanced anaplastic carcinoma in a 41-year-old man who presented with splenic infarction.[ncbi.nlm.nih.gov]
  • Despite technical and therapeutic advances, the prognosis remains dismal; the average survival time after diagnosis is characteristically only five to eight months.[ncbi.nlm.nih.gov]
  • Prognosis The prognosis of splenic infarctions varies enormously, depending on the cause and severity of the disease.[teachmesurgery.com]
  • Treatment and prognosis Initial management usually consists of hydration, analgesics, and frequent monitoring, with the resolution of symptoms in 7-14 days. Splenectomy was performed for persistent symptoms or complications.[radiopaedia.org]
  • This occurrence is caused by a wide variety of underlying disease states with prognosis dependent on the causative illness.[ncbi.nlm.nih.gov]

Etiology

  • Etiologies included hematologic disorders (n 35), thromboembolic disorders (n 17), and other diseases (n 7).[ncbi.nlm.nih.gov]
  • Abstract Evans syndrome is a very rare hematologic autoimmune disease, characterized by a direct Coombs' positive hemolytic anemia and immune thrombocytopenic purpura without a known underlying etiology.[ncbi.nlm.nih.gov]
  • However, patients may present with culture-negative cloudy dialysate effluent and after ruling out atypical infectious etiologies, other intraabdominal causes should be considered in the differential diagnosis.[ncbi.nlm.nih.gov]
  • […] infarcts were more likely to be associated with fever (20% vs. 63%, p 0.05) and leukocytosis (75% vs. 33%, P 0.06) CONCLUSIONS: The clinical presentation of splenic infarction in the modern era differs greatly from the classical teaching, regarding etiology[ncbi.nlm.nih.gov]
  • Cardiogenic emboli were the predominant etiology (20/32, 62.5%) and atrial fibrillation was frequent. Other patients had autoimmune disease (12.5%), associated infection (12.5%), or hematological malignancy (6%).[ncbi.nlm.nih.gov]

Epidemiology

  • Smith 1Division of Infectious Diseases and Epidemiology, Department of Medicine, New York, New York2Department of Pathology and Laboratory Medicine, St.[doi.org]
  • Epidemiology Splenic infarcts are considered a rare cause of abdominal pain although the exact prevalance is unclear.[ncbi.nlm.nih.gov]
  • […] the cohort. [1] History of the Procedure One of the earliest descriptions of splenic infarct was made in Germany in 1896, after a splenic infarction was seen microscopically following splenectomy for endocarditis (presumably due to septic emboli). [2] Epidemiology[thehealthscience.com]
Sex distribution
Age distribution

Pathophysiology

  • These findings demonstrate the pathophysiology of SCT, and may help with the diagnosis of this disease. KEYWORDS: Sickle cell anemia; Sickle cell trait; Splenic infarction; Splenic vein; Venous thromboembolism[ncbi.nlm.nih.gov]
  • Pathophysiology The splenic artery (branching off the celiac artery) supplies blood flow to the spleen in combination with the short gastric arteries (branches off of the left gastroepiploic artery).[ncbi.nlm.nih.gov]
  • […] splenic bleeding Operative etiologies [8, 9] Pancreatectomy Liver transplant Miscellaneous etiologies Splenic vein thrombosis Pancreatitis Amyloidosis Sarcoidosis Pancreatic cancer Adult respiratory distress syndrome (ARDS) Postpartum toxic shock syndrome Pathophysiology[thehealthscience.com]
  • Patient 4o years of age and younger are more likey to have underlying hematologic illness while patients 40 years of age and older are more likely to suffer splenic infarct due to thromboembolic diseases. [5] Pathophysiology The splenic artery (branching[ncbi.nlm.nih.gov]
  • In all these cases the pathophysiological mechanism is the breakdown of blood supply to the spleen resulting from a lesion of the splenic artery [13-15].[ispub.com]

Prevention

  • Herein, we present a patient who developed splenic infarction after N-butyl-cyanoacrylate injection for gastroesophageal varices type 2 and discuss the potential reasons and tips to prevent the occurence of embolization.[ncbi.nlm.nih.gov]
  • The 4 previous case reports are reviewed and the implication of this finding for preventive strategies is highlighted.[ncbi.nlm.nih.gov]
  • Furthermore in order to prevent OPSI, only in case of clear, persistent symptoms or complications it may be necessary surgical laparoscopic or open approach.[ncbi.nlm.nih.gov]
  • To prevent splenic infarction in LSPDP, we should carefully isolate the pancreatic parenchyma from the splenic vessels, and must avoid drawing tightly on the vessel loop encircling splenic vessels.[ncbi.nlm.nih.gov]
  • It is vital to identify the cause of this phenomenon to prevent morbidity and mortality as it is usually the presentation of a larger disease entity. To cite this abstract: Chernyavsky S, Mecca J, Shrenselz J.[shmabstracts.com]

References

Article

  1. Ozakin E, Cetinkaya O, Balogu K, Acar N, Cevik AA. A Rare Cause of Acute Abdominal Pain: Splenic Infarct (Case Series). Turk J Emerg Med. 2015;15(2):96-99.
  2. Rabushka LS, Kawashima A, Fishman EK. Imaging of the spleen: CT with supplemental MR examination. Radiographics. 1994;14(2):307-332.
  3. Lawrence YR, Pokroy R, Berlowitz D, Aharoni D, Hain D, Breuer GS. Splenic infarction: an update on William Osler's observations. Isr Med Assoc J. 2010;12(6):362-365.
  4. Ami S, Meital A, Ella K, Abraham K. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome. Mazen ES, ed. Medicine (Baltimore). 2015;94(36):e1363.
  5. Hwang J-H, Lee C-S. Malaria-Induced Splenic Infarction. Am J Trop Med Hyg. 2014;91(6):1094-1100.
  6. Antopolsky M, Hiller N, Salameh S, Goldshtein B, Stalnikowicz R. Splenic infarction: 10 years of experience. Am J Emerg Med. 2009;27:262–265
  7. Nores M, Phillips EH, Morgenstern L, Hiatt JR. The clinical spectrum of splenic infarction. Am Surg. 1998 Feb;64(2):182-188.
  8. Vancauwenberghe T, Snoeckx A, Vanbeckevoort D, Dymarkowski S, Vanhoenacker FM. Imaging of the spleen: what the clinician needs to know. Singapore Med J. 2015;56(3):133-144.

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Last updated: 2018-06-22 05:34