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]

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

  Splenic infarct: Splenic infarct with a wedge shaped non vascularized spenic lesion Splenic infarct: Splenomegaly with a small peripheral splenic infarct Splenic infarct: Splenic infarct with a non vascularized wedge shaped hypoechoic area Splenic infarct [ultrasoundcases.info]

  AJR 2014; 203:315–322 Differential Diagnosis of Acute LUQ Pain Spleen • Infarct and sickle cell crisis • Splenomegaly • Rupture • Abscess and infection • Ruptured splenic artery aneurysm • Splenic torsion • Splenic vein thrombosis Splenic Infarction: [ctisus.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]

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

• 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]

  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]

• Acutely Ill Patient

  Examination showed an acutely ill patient with a 39°C fever, oral ulcers, haemorrhagic gingival hyperplasia, bilateral haemorrhagic nasal discharge with crusts, diffuse necrotic purpura, neuritis, and black discoloration of some fingers and toes. [ard.bmj.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]

• Abdominal 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]

  Chronic mesenteric ischaemia is an important cause of abdominal pain, especially in older patients with risk factors for vascular disease. [ncbi.nlm.nih.gov]

  Abstract Abstract 4775 Abdominal pain is a common complaint among all ages of patients. [bloodjournal.org]

• 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]

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

• 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. 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]

• 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]

  A 24-year old Sudanese gentleman with known SCT presented with a 2-day history of severe left upper quadrant (LUQ) abdominal pain. [imj.ie]

• Protein S Deficiency

  Hypercoagulability in transient protein C and protein S deficiency might contribute to the development of splenic infarction in infectious mononucleosis. [ncbi.nlm.nih.gov]

  C or protein S deficiency, oral contraceptives, lupus anticoagulant Erythropoietin therapy Idiopathic venous thrombosis Polycythemia vera Sickle hemoglobinopathies [7] Embolic disorders Endocarditis Atrial fibrillation Prosthetic mitral valve Paradoxical [thehealthscience.com]

• 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

  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 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]

• Costovertebral Angle Tenderness

  Physical examination revealed hypertension, subfebrile temperature, and costovertebral angle tenderness. [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]

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]

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

The frequency of visualized splenic infarcts may be rising because of the following factors: Etiology There are numerous etiologies of splenic infarct. [thehealthscience.com]

[…] 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]

Epidemiology Splenic infarcts are considered a rare cause of abdominal pain although the exact prevalance is unclear. [ncbi.nlm.nih.gov]

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

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

[…] 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]

ACE inhibitors also prevent conversion of angiotensin I to angiotensin II (a potent vasoconstrictor), thus reducing afterload to help prevent heart failure. [medical-dictionary.thefreedictionary.com]

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.