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].

• Fever

  Recent data suggest that antiphospholipid antibodies may be responsible for certain clinical manifestations of acute Q fever. [ncbi.nlm.nih.gov]

• Gaucher Disease

  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]

  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 less common causes include infectious mononucleosis, sickle cell disease, Gaucher disease, wandering spleen, sepsis, pancreatitis, infiltrative diseases, and collagen-vascular diseases [ 3 ]. [karger.com]

• Fatigue

  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]

  Five days prior to admission, he had continuous fatigue, fever, and sore throat lasting for 1 week. [kjim.org]

  Ten days later, the patient was readmitted to the hospital with spiking fevers, chills, fatigue, weakness, and recurrent pancytopenia. [doi.org]

  Patients are taught not only to measure their pulse but also to assess their response to exercise in terms of fatigue, ease of breathing, and perceived workload. [medical-dictionary.thefreedictionary.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]

• Animal Bite

  Animal bites are typically harmless, but in rare cases infections introduced by such bites can be fatal. [ncbi.nlm.nih.gov]

• Splenomegaly

  Physical examination on admission revealed a palpable splenomegaly. [ncbi.nlm.nih.gov]

  Splenic infarction is also more common in hematological disorders with associated splenomegaly, such as the myeloproliferative disorders. [en.wikipedia.org]

  The ultrasound was significant for multiple hypodensities in the spleen and splenomegaly. [emdocs.net]

• Abdominal Pain

  The main presenting feature of a splenic infarction is abdominal pain, typically situated in the upper left quadrant. [symptoma.com]

  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]

• Left Upper Quadrant Pain

  The left upper quadrant pain resolved after 8 days and the patient remains asymptomatic 2 years post-procedure. [ncbi.nlm.nih.gov]

• Nausea

  In nine, this was associated with nausea and vomiting. Three were febrile and all had a tender splenomegaly. [ncbi.nlm.nih.gov]

  Nausea, vomiting, fever, and chills are frequent accompanying complaints. [symptoma.com]

  A 38-year-old black woman presented to the emergency department with 2 days of left upper quadrant abdominal pain, nausea, and intractable vomiting. [annals.org]

  Clinical presentation includes acute left upper quadrant pain, fever, leukocytosis, nausea and vomiting. [shmabstracts.com]

• 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]

  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]

  CONCLUSION We believe this to be the first case report in the English literature of an anaplastic pancreatic carcinoma presenting as an acute abdomen due to splenic infarction. [pancreas.imedpub.com]

  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

  A 7-year-old girl was admitted with a severe abdominal pain. Abdominal ultrasound and CT revealed a large splenic infarction, leading to the diagnosis of chronic myeloid leukemia. [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]

  Such cases can present acutely with severe abdominal pain and therefore it is important that Irish physicians are familiar with this rare but highly treatable complication of SCT. [imj.ie]

• 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]

  Following admission, intravenous Piperacillin-Tazobactam was commenced in response to pyrexia (39.1 C), tachycardia (120beats/min) and a rising CRP (315mg/dL). [imj.ie]

  Clinical manifestations range from the subclinical to pleuritic chest pain, dyspnea, hemoptysis, and tachycardia. in·farc·tion ( in-fark'shŭn ), 1. [medical-dictionary.thefreedictionary.com]

  Chest examination was clear and the cardiac examination did not show any tachycardia, murmur, gallop or rub. [em-consulte.com]

• 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]

• Costovertebral Angle Tenderness

  Physical examination revealed hypertension, subfebrile temperature, and costovertebral angle tenderness. [ncbi.nlm.nih.gov]

• Lethargy

  A 16-year-old male patient with known hereditary spherocytosis presented with a 4-day history of chest pain and lethargy. On admission, he had a low-grade fever and was grossly anaemic; examination revealed splenomegaly. [ncbi.nlm.nih.gov]

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

  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]

• Capnocytophaga Canimorsus

  Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. [ncbi.nlm.nih.gov]

• Capnocytophaga

  Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. [ncbi.nlm.nih.gov]

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.