Splenic infarction: a rare cause of acute abdominal pain presenting in an older patient with primary antiphospholipid antibodies syndrome

Abstract

Splenic infarction is an uncommon condition that is rarely encountered in emergency and internal medicine. This condition is usually associated with systemic conditions such as hypercoagulable states, hemoglobinopathies, systemic lupus erythematosus, hematologic disorders, and cardiac thromboembolism during atrial fibrillation and endocarditis [1].We describe a case of a woman with an acute abdominal pain due to splenic infarction from splenic artery thrombosis caused by a diagnosis of primary antiphospholipid antibodies syndrome (APS).An 81-year-old woman was admitted to the emergency department(ED) of the Padova Hospital complaining of a sudden onset and constant abdominal pain localized in the epigastric-left upper quadrant, accompanied by nausea and vomiting. The patient did not report any recent abdominal nor thoracic trauma.The pain was worsened with deep inspiration. There was no radiation, and no association with meals or physical efforts. There was neither fever, dysuria, hematuria, melena, nor any changes in bowel habit. She had a past history of mild arterial hypertension, partial gastrectomy for peptic ulcer, and was a moderate tobacco user. The patient had neither family nor personal history of known arterial, vein thrombosis nor spontaneous abortion or fetal loss. On physical examination there was moderate tenderness on palpation of the epigastrium and left upper abdominal quadrant, with normal bowel sounds. The chest auscultation was normal and the cardiac examination did not show any pathological condition. No abdominal aortic bruits were heard, and the rectal examination was normal. Arterial blood pressure, pulse rate and respiratory rate were normal. The ECG and chest X-ray study were unremarkable. Plain abdominal X-ray study showed a non-specific pattern. Laboratory findings showed a mild leukocytosis, elevation of CRP and D-dimer plasma levels, with normal myoglobin and troponin I concentrations.We obtained a gastroscopy that showed only moderate gastritis. Acute pancreatitis was ruled out by the observation of normal amylase plasma levels. An abdominal ultrasound study showed a normal pancreas, the liver showed mild increased echogenicity with normal volume and morphology, as well as a normal gallbladder, normal portal vein and right kidney, with a hypotrophic left kidney. No alterations were observed of the urinary bladder, uterus and ovaries. The spleen showed a bipolar diameter of 9 cm with dishomogeneous echogenicity and the presence of a few hypoechogenic areas the larger being 23 mm in diameter (not shown).A CT scan of the abdomen revealed a few huge parenchymal defects of the spleen (the largest with 25 mm diameter), consistent with a splenic infarction, and a thrombosis of the splenic artery distal to the origin (Fig. 1). Furthermore, on the same CT scan it was possible to confirm the reduced volume of the left kidney with presence of complete occlusion of the left renal artery. The right kidney appeared completely normal as well as the right renal artery. Blood coagulation tests reve...

The role of emergency ultrasound in the diagnosis of acute non-traumatic epigastric pain

“…Finally, splenic infarction has been described as a rare cause of acute abdominal pain in an older patient with primary antiphospholipid antibodies syndrome [34].…”

A rare cause of left upper quadrant abdominal pain

“…The results of routine laboratory findings, including b-HCG, ALT, AST, pancreatic amylase, bilirubin, creatinine, coagulation parameters were within normal range, except for a mild anemia (Hb = 11.2 g/dl; Htc = 33.4%; VCM = 80.5 fl), mild LDH (903 U/L) and PCR increase (3.29 mg/dl) [1,2].…”

“…The liver was slightly enlarged on palpation. The remainder of the examination was unremarkable.The results of routine laboratory findings, including b-HCG, ALT, AST, pancreatic amylase, bilirubin, creatinine, coagulation parameters were within normal range, except for a mild anemia (Hb = 11.2 g/dl; Htc = 33.4%; VCM = 80.5 fl), mild LDH (903 U/L) and PCR increase (3.29 mg/dl) [1,2].The ultrasound (US) abdominal examination [3] revealed an abnormal and inhomogeneous splenic echostructure because of multiple lesions, with the characteristics of ischemic infarctions and scarring (Fig. 1, see white arrows); there were no other pathological findings in the liver, kidneys, pancreas, abdominal aorta and pelvic organs.…”