Acute nontraumatic splenic infarctions at a tertiary-care center: causes and predisposing factors in 123 patients

[The causes of splenic infarction: An almost systematic review of the literature]

INTRODUCTION

Splenic infarction is a rare event in clinical practice, diagnosed by CT scan. There are many causes. They often determine the treatment given. However, there is no consensus on etiological investigations.

METHODS

We present here an almost systematic review of the literature, based on data available on Pubmed from 1991 to 2022. Using the keywords "splenic infarct", from 1893 references, 11 cohort studies and 867 clinical cases were included in this review. Articles written in languages using alphabets other than Latin were excluded.

RESULTS AND CONCLUSIONS

Analysis of these various studies has enabled us to draw up a list that is intended to be as exhaustive as possible of the causes of splenic infarction. The most frequent are emboligenic heart disease, hematological malignancies, solid neoplasia and certain infections. The descriptions available in the literature were mainly based on isolated clinical cases, not always making it possible to establish a causal link with the disease described, especially as around 20% of reported cases of splenic infarction were asymptomatic and potentially of incidental discovery. Based on the findings of this literature review, we propose a protocol for the etiological assessment of splenic infarcts.

Splenic Infarction with Myocardial Injury in a Diabetic Patient: A Case Report

Splenic infarction (SI) is an uncommon complication of type 2 diabetes (T2D). Diabetes predisposes individuals to blood vessel abnormalities, such as atherosclerosis or thrombosis, increasing the risk of vessel occlusion and subsequent tissue infarction. If the diabetic patient has other serious diseases, such as a severe pneumonia infection and acute cardiac infarction, SI incidence may go unrecognized, making it challenging for physicians to identify. This case report discussed an 80-year-old hospitalized diabetic woman with a history of chronic bronchitis and 20 years of T2D who suffered an SI. The patient was at elevated risk for thrombosis of atrial fibrillation, manifested as an embolism of the spleen characterized by a high concentration of white blood cells. This patient also demonstrated a rapid increase in cardiac biomarkers troponin I, suggesting acute myocardial infarction (AMI) and increased amylase, which could not preclude the concern about the existence of acute pancreatitis. Abdominal CT displayed the calcification of only the splenic and other arteries, and low-density shadows were observed at the center portion of the spleen. This case demonstrated the significant occurrence of thrombotic complications in various blood vessels of multiple organs in T2D patients. Thus, clinicians should be aware of the possibility of simultaneous acute vascular infarction of several organs in diabetic patients with prior vascular constriction.

Case Report: Acute Renal and Splenic Infarctions Secondary to Atrial Fibrillation

Acute renal and splenic infarctions are an uncommon condition that can result from obstruction or decrease of renal and splenic arterial flow. We described a 73-year-old woman who presented with right flank pain and nocturnal dyspnea. The computed tomography (CT) scan with intravenous contrast showed multiple infarcts in both bilateral kidneys and spleen. Serum creatinine clearance was impaired. Further investigation by electrocardiogram (ECG) and 24-h Holter revealed that the patient had paroxysmal atrial fibrillation (PAF). Transthoracic and transesophageal echocardiographic findings were unremarkable except for severe spontaneous echo contrast (SEC) in the left atrial appendage. The development of thromboembolic renal and splenic infarction was attributed to embolism caused by atrial fibrillation. Anticoagulant therapy was initiated with low molecular weight heparin (LMWH) and followed by an oral anticoagulant. To manage PAF and prevent further embolism, the “One-stop” procedure, including atrial fibrillation catheter ablation and left atrial appendage occlusion (LAAO), was applied to this patient. Follow-up at 1 month showed normal sinus rhythm, improved renal function, and relieved renal and splenic infarction.

Isolated Splenic Infarction: An Initial Manifestation of Postoperative Atrial Fibrillation

Splenic infarction is an uncommon cause of abdominal pain. In this article, we present a case of isolated splenic infarction presenting with severe abdominal pain, nausea, and with associated generalized weakness. Computed tomography (CT) abdomen and pelvis with contrast revealed multiple splenic infarctions of the entire lower pole with occlusion of the branch splenic arteries, while CT abdomen without contrast was unremarkable. Etiology was later revealed to be thromboembolism secondary to atrial fibrillation. It was managed with anticoagulation. To our knowledge, this is the second case of splenic infarction presenting as an initial manifestation of atrial fibrillation (AF), reported in the literature.

Anticoagulant Therapy Is Associated With Decreased Long-Term Mortality in Splenic Infarction Patients: A Multicenter Study

Background: Patients with splenic infarction (SI) are associated with a prothrombotic state and are vulnerable to subsequent thromboembolic complications. However, due to its rarity, there is no established treatment modality in this population. We aimed to examine the effect of anticoagulant therapy in SI patients.

Methods: We performed a multicenter retrospective cohort study of 86 SI patients. Patients were categorized as anticoagulant users and anticoagulant non-users. The associations between anticoagulant therapy, all-cause mortality, thromboembolic events and bleeding events were evaluated.

Results: Forty-five patients (52.3%) received anticoagulant therapy during the follow-up periods. The all-cause mortality rate was 6.86 per 100 patient-years. Anticoagulant therapy was associated with 94% improved survival (HR = 0.06; Cl 0.007–0.48; p = 0.008), while the risk factors for all-cause mortality were prior stroke (HR = 13.15; Cl 2.39–72.27; p = 0.003) and liver cirrhosis (HR = 8.71; Cl 1.29–59.01; p = 0.027). Patients with anticoagulant therapy had a higher event-free survival curve for thromboembolic complications (p = 0.03) but did not achieve a significant difference after adjustment using the Cox regression model as a time-dependent covariate (HR = 0.57; Cl 0.13–2.45; p = 0.446). There was no significant difference in the risk of bleeding events between the groups (p = 0.728).

Conclusions: Anticoagulant therapy in patients with SI was associated with better survival and was not related to an increased bleeding risk.

Risk assessment and prognostic analysis of patients with splenic infarction in emergency department: a multicenter retrospective study

Splenic infarction is a thromboembolic disease that is frequently missed in acute settings. Previous reviews were rarely presented from a clinical perspective. We aimed to evaluate the clinical characteristics, risk factors with diagnostic value, and prognostic factors using large cohort data and a matched case–control study method. A retrospective medical record review of six hospitals in Taiwan from January 1, 2005, to August 31, 2020, was conducted. All patients who underwent contrast CT with confirmed the diagnosis of splenic infarction were included. Their characteristics were presented and compared to a matched control group with similar presenting characteristics. Prognostic factors were also analyzed. A total of 130 cases were included, two-thirds of whom presented with abdominal pain. Atrial fibrillation was the most common associated predisposing condition, followed by hematologic disease. A higher proportion of tachycardia, positive qSOFA score, history of hypertension or atrial fibrillation, leukocytosis, and thrombocytopenia were found in splenic infarction patients compared to their counterparts. An underlying etiology of infective endocarditis was associated with a higher proportion of ICU admission. Splenic infarction patients often presented with left upper abdominal pain and tachycardia. A history of hypertension, atrial fibrillation, a laboratory result of leukocytosis or thrombocytopenia may provide a clue for clinicians to include splenic infarction in the differential list. Among the patients diagnosed with splenic infarction, those with an underlying etiology of infectious endocarditis may be prone to deterioration or ICU admission.

Clinical characteristics and outcomes of splenic infarction in cancer patients: a retrospective, single center report of 206 cases

Cancer patients have a high risk of thromboembolic events including splenic infarct (SI). However, risk factors for SI in cancer patients are poorly understood, and the utility of systemic anticoagulation in such patients is uncertain. We performed a retrospective cohort study of all cancer patients with SI treated at Yale New Haven Hospital from 2008 to 2017. Central review of radiology imaging was performed to confirm the diagnosis of SI. Baseline differences in variables among patients with and without recurrent SI were compared using Fisher's exact test, Pearson's χ² test, and t-test. Multivariable regression models were conducted to identify factors associated with recurrent SI. Of 206 patients with cancer and SI, 42 had a prior venous thromboembolic event, while 29 had atrial fibrillation/flutter. At a median follow-up of 11.4 months (range: 0-142.3 months), 152 patients underwent follow-up imaging, with only 6 having recurrent SI. The use of anticoagulation after initial SI was associated with a nonsignificant increase in recurrent SI (p = 0.054) and was not associated with development of venous thromboembolism after SI (p = 0.414). In bivariate analyses, the risk of recurrent SI showed a significant association with lower platelet counts (p < 0.001) and with atrial fibrillation/flutter (p = 0.036). In a multivariable logistic regression model, no variables were identified that were associated with a higher risk of recurrent SI. SI in cancer patients is typically an isolated event with low recurrence risk. Anticoagulation use should be guided by other thromboembolic risk factors.

Assessment of Clinical Conditions Associated With Splenic Infarction in Adult Patients

This case series examines the clinical conditions associated with splenic infarction of adult patients between 2010 and 2015 from computed tomographic imaging scans.

plenic vein thrombosis: rare cause of abdominal pain

-An 83-year-old woman with a history of hypertension, diabetes and paroxysmal atrial fibrillation anticoagulated with acenocoumarol was brought to the emergency department due to dyspnoea. At admission, the patient reported a 1-week history of malaise, shortness of breath and non-productive cough. She denied fever but reported pain on the left flank. On examination, auscultation showed arrhythmic tones and crackles in the left lower lung field. Laboratory findings showed leucocytosis of 15.32×10³/μL, and the C reactive protein was 177 mg/L. The activated partial thromboplastin time was 54.8 s, and the international normalised ratio was 7.09. A chest X-ray showed left lower lobe consolidation with pleural effusion. Point-of-care ultrasound was performed using a low-frequency curved transducer (2-5 MHz). The probe was placed in the left posterior axillary showing a pulmonary consolidation, but also a hypoechoic lesion in the spleen was found (figure 1).emermed;37/1/30/F1F1F1Figure 1Ultrasound image of the spleen in longitudinal section demonstrating a large, hypoechoic, wedge-shaped lesion. QUESTION: What is the most likely diagnosis?Splenic abscessSubcapsular splenic haematomaSplenic infarctionSplenic hydatid cyst For answer see page 2.

Acute renal and splenic infarctions: a review

BACKGROUND

Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features.

AIM

The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI).

DESIGN

A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted.

METHODS

All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations.

RESULTS

A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79-126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups.

CONCLUSION

Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up.

A practical approach to infarction of the spleen as a rare manifestation of multiple common diseases

INTRODUCTION

There are insufficient data on the aetiologic factors underlying splenic infarction (SI). Therefore, there is no consensus regarding the appropriate diagnostic approach.

METHODS

We conducted a retrospective analysis of all patients admitted with SI from January 2004 to December 2014. Medical records were screened for the clinical presentation, underlying causes, associated medical conditions and methods of patient evaluation.

RESULTS

We found 89 subjects with 90 episodes of SI. Presentation of SI was characterized by abdominal, flank and chest pain (82.2%, 18.9%, 7.8%, respectively); leukocytosis (in 67% of tested subjects); elevated LDH (72%), CRP (97.5%) and D-Dimer (100%). The main underlying mechanisms were cardioembolic (54.4%), vascular (20%), haematologic disorders (15.6%) and multiple causes (21.1%). Atrial fibrillation and atherosclerosis were common in older patients (age > 70 years) while antiphospholipid syndrome occurred exclusively in younger individuals. SI was the presentation of previously unknown medical conditions in 38% of patients. Abdominal CT, ECG, echocardiography and blood cultures demonstrated the highest diagnostic yield.

CONCLUSIONS

Contributing factors are identified in the majority of SI patients. We recommend CT, ECG, echocardiography and blood cultures in all cases. Atrial fibrillation should be sought in older patients, while APLS and haematologic disorders should be suspected in younger ones. KEY MESSAGES There is no consensus regarding the diagnostic approach and management of splenic infarction. Cardiovascular disease and atrial fibrillation are the main causes for SI in elderly subjects while hematological, infectious and other causes are more prevalent in younger ones. Our data strongly suggests a high diagnostic yield for CT scan, ECG, blood culture and echocardiogram in every patient with SI.