Splenic rupture complicating periinterventional glycoprotein IIb/IIIa antagonist therapy for myocardial infarction in polycythemia vera

Abstract

Polycythemia vera is a myeloproliferative disorder predisposing to thromboembolic and bleeding complications. We report the case of a patient with polyglobuly, leukocytosis, and thrombocytosis, who suffered from acute ST-segment elevation myocardial infarction due to thrombotic high-grade pre-stent stenosis two months after percutaneous coronary intervention for complex coronary one vessel disease. Following re-PTCA and stent implantation in conjunction with periinterventional GP IIb/IIIa antagonist treatment, the patient was initially symptom free for about two hours before rapidly developing signs of a hemorrhagic shock. An abdominal CT scan showed splenic rupture with massive intraabdominal hemorrhage as a consequence of secondary bleeding into multiple pre-existing splenic infarctions. The patient's condition stabilized after emergency splenectomy. Subsequent bone marrow biopsy revealed the presence of polycythemia vera. Post-operatively, the patient was treated with the anti-platelet agents aspirin and clopidogrel to prevent subacute stent thrombosis. Additionally, cyto-reductive therapy with hydroxyurea was initiated because of a further increase in the platelet count. In patients with polycythemia vera, the indication for treatment with GP IIb/IIIa antagonists should be carefully weighed against the potentially serious bleeding complications. Should treatment be established, a risk stratification using abdominal sonography and bleeding time testing is recommended, while during treatment red blood count, platelet count, coagulation tests, and hemodynamic parameters should be closely monitored.

Splenic Infarction in Patients with Philadelphia-negative Myeloproliferative Neoplasms

“…Thus, splenic infarction is not very serious and does not require particular attention. However, some patients complained of severe abdominal pain, and several case reports have described serious complications (splenic rupture, peritoneal bleeding, and peritonitis) in MPN patients (19)(20)(21). In Intern Med 61: 3483-3490, 2022 DOI: 10.2169/internalmedicine.9124-21 addition, abscess formation and functional asplenia attributable to splenic infarction have been reported in patients with other clinical conditions (30)(31)(32)(33).…”

“…Splenic infarctions develop in patients with various hematological disorders; they have been extensively described in patients with sickle cell disease (13) and hematological malignancies, in-cluding lymphoma and leukemia (14)(15)(16)(17). Such infarctions also develop in patients with Ph -MPN (18); serious complications include splenic rupture, intraperitoneal bleeding, and peritonitis (19)(20)(21). However, most data are those of case reports and thus are difficult to generalize and apply in routine clinical practice.…”

Spontaneous splenic rupture in polycythemia vera

“…To date, there are only four cases in world literature of atraumatic spontaneous splenic rupture associated with PV, only one of which has been since the revised diagnostic criteria for polycythemia vera (elevated hemoglobin, JAK2 V617F mutation, and subnormal serum erythropoietin). All cases presented with splenomegaly and hemodynamic instability and required an exploratory laparotomy at which time a splenectomy was performed [9][10][11][12].…”

Splenic rupture following thrombolysis treatment for acute myocardial infarction

“…Two of these cases were associated with a history of significant trauma prior to thrombolysis; One involved a patient who had a road traffic accident resulting in a fractured pelvic six months prior (5) and the other had experienced a fall from a ladder 6 weeks earlier (6). Splenic rupture following administration of thrombolytic agents has been reported in the presence of myeloproliferative disorders, such as polycythemia vera (7) and in those with splenomegaly secondary to infection (8). This case is unusual, as the patient had no history of trauma, myeloproliferative disorders or splenomegaly.…”