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

  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]

• Pain

  A 72-year-old female previously diagnosed with cirrhosis was admitted for left upper quadrant abdominal pain for two days. [ncbi.nlm.nih.gov]

  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. [symptoma.com]

• Fever

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

  Persona opinion of the clinical evolution of our patient was as follows: A) epigastric pain that began 15 days before admission (with fever) was due to splenic infarction; B) symptoms referred by the patient 3 days before admission (pain, fever and lipothymia [minervamedica.it]

• Anemia

  An 18-year-old woman with infectious mononucleosis developed splenic infarction and severe anemia. [ncbi.nlm.nih.gov]

  Pyruvate kinase deficiency, infectious mononucleosis, hemolytic anemia with cold autoantibodies and massive splenic infarction [letter, in French]. Presse Med. 1990;19:818–819. PubMed Google Scholar 17. [doi.org]

• Chills

  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]

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

  Fever and chills develop in some cases. 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]

  Fever and chills develop in some cases. It has to be differentiated from other causes of acute abdomen. [en.wikipedia.org]

  Not associated with fever/ chills/ rigors/ trauma / weight change/ shortness of breath/ urinary/ bowel complaint. Medications at home significant only for oral contraceptives. [gastrohep.com]

• 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]

  cardiac disorders (valvular disease, endocarditis), vascular disorders such as aortic atherosclerosis, drugs (cocaine, erythropoietin…), and other miscellaneous causes (Gaucher disease, pancreatitis…). [em-consulte.com]

  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]

• Abdominal Pain

  Patients with abdominal pain and known or suspected infectious mononucleosis mandate evaluation for these complications, which can have significant morbidity or mortality. [ncbi.nlm.nih.gov]

  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. [symptoma.com]

• 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]

• Nausea

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

  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]

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

  He had been suffering from this pain for about 6 months before a road accident, but had increased in the last month, without nausea or vomiting. [prodiagnosis.org]

• 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. An abdominal CT scan is the most commonly used modality to confirm the diagnosis, although abdominal ultrasound can also contribute. [definitions.net]

  It has to be differentiated from other causes of acute abdomen. [en.wikipedia.org]

  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]

• Upper Abdominal Pain

  We report a 38-year-old mestizo man with the sudden onset of left upper abdominal pain while climbing Mt. Fuji, which is the highest mountain in Japan. Enhanced computed tomography showed splenic infarction. [ncbi.nlm.nih.gov]

  Septic thromboemboli may result in splenic abscesses, which present with sepsis and left upper abdominal pain. [emedicine.medscape.com]

• Thrombosis

  MTHFR C677T (methylenetetrahydrofolate) gene homozygote mutation was a risk factor for thrombosis. [ncbi.nlm.nih.gov]

  Pancreatitis and pancreatic cancer are the most common causes of splenic vein thrombosis. [bloodjournal.org]

• 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]

• Shoulder Pain

  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. [symptoma.com]

  The most common presenting symptom is left-upper-quadrant abdominal pain (up to 70%). Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign). [emedicine.medscape.com]

  The most common presenting symptom is left – upper quadrant abdominal pain (up to 70%). Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign). [thehealthscience.com]

• Left Shoulder Pain

  The most common presenting symptom is left-upper-quadrant abdominal pain (up to 70%). Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign). [emedicine.medscape.com]

  The most common presenting symptom is left – upper quadrant abdominal pain (up to 70%). Additional symptoms include fever and chills, nausea and vomiting, pleuritic chest pain, and left shoulder pain (Kehr sign). [thehealthscience.com]

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]

• Leukocytosis

  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]

  Patients with sickle cell trait and splenic infarction have been documented to have leukocytosis and fever in the first 72 hours. Patients who are having a sickle cell crisis may have an associated marrow response (leukocytosis, reticulocytosis). [cmaj.ca]

  Associated symptoms, leukocytosis or increased serum lactate dehydrogenase occurred inconsistently (∼25% each). Chest X-ray showed suggestive Lt. supra-diaphragmatic findings in 22%. [doi.org]

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]

They all survived with medical treatment (except one surgical treatment). [doi.org]

They occur in elderly men and are associated with a very poor prognosis. We report a case of advanced anaplastic carcinoma in a 41-year-old man who presented with splenic infarction. He had a prolonged survival of 16 months from diagnosis. [ncbi.nlm.nih.gov]

Prognosis The prognosis of splenic infarctions varies enormously, depending on the cause and severity of the disease. [teachmesurgery.com]

The histologic spectrum, prognosis, and histogenesis of the sarcomatoid carcinoma of the pancreas. Cancer 1977; 39:1181-9. [PMID 912652] Martin A, Texier P, Bahnini JM, Diebold J. [pancreas.imedpub.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]

Etiologies included hematologic disorders (n = 35), thromboembolic disorders (n = 17), and other diseases (n = 7). [ncbi.nlm.nih.gov]

A systematic literature review was done to compile a complete list of SI etiologies. SI was found in 32 patients, 0.016% of admissions. Ages ranged from 18 to 86 (median 64) years. [doi.org]

Complications Some complications are encountered, more frequently in patients with an embolic etiology. [radiopaedia.org]

Smith 1 Division of Infectious Diseases and Epidemiology, Department of Medicine, New York, New York 2 Department 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]

These findings demonstrate the pathophysiology of SCT, and may help with the diagnosis of this disease. [ncbi.nlm.nih.gov]

The pathophysiology of splenic infarction is poorly known. Treatment being non-surgical in most cases, histological analysis is rarely possible. [doi.org]

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]

[…] 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]

The 4 previous case reports are reviewed and the implication of this finding for preventive strategies is highlighted. [ncbi.nlm.nih.gov]

In: Centers for Disease Control and Prevention, Surveillance Summaries, March 29, MMWR Surveill. Summ., 2002, vol. 51 No. [doi.org]

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