Medical Image of the Week: Splenic Infarction

Figure 1. Axial computed tomography demonstrating a wedge-shaped area of hypo-enhancement in the spleen in keeping with a splenic infarct.

Figure 2. Coronal computed tomography demonstrating a wedge-shaped area of hypo-enhancement in the spleen .

A 52-year-old Hispanic woman with a past medical history significant for Type 1 diabetes mellitus, hypertension, and rheumatoid arthritis presented with left upper quadrant pain for one day. Her review of systems was positive for bloating, severe epigastric and left upper quadrant tenderness that radiated to the back and left shoulder, nausea with non-bilious emesis, and diarrhea for one day prior to admission. Physical exam only revealed epigastric and left upper quadrant tenderness to light palpation without rebound or guarding.  Abdominal computed tomography of the abdomen demonstrated a new acute or subacute splenic infarct with no clear evidence of an embolic source in the abdomen or pelvis (Figures 1 and 2). Echocardiogram with bubble study and contrast did not demonstrate valve abnormalities, cardiac mass, vegetation, valve or wall motion abnormalities and no evidence of patent foramen ovale.

Splenic infarction should be suspected when patients present with sharp, acute left upper quadrant pain radiating to the left shoulder (Kehr sign). Splenic friction rub may be auscultated but CT is diagnostic (1). Splenic infarction is an uncommon condition, with compiled reports from a 10-year retrospective study of an academic center showing only 32 cases (0.016% of admission). Causes included cardiogenic emboli (62.5%), autoimmune disease (12.5%), associated infection (12.5%), or hematological malignancy (6%) (2). Active malignancy, embolic events from atrial fibrillation or infective endocarditis, and inflammatory disorders appear to be consistent causes for splenic infarct as demonstrated in a compilation study of 123 case reports of non-traumatic splenic infarction (3). Management includes supportive care and treating the underlying cause, embolic (e.g. endocarditis), vasculitis, or in situ occlusion from predisposing conditions (e.g. sickle cell, polycythemia vera, chronic myeloid leukemia, or myelofibrosis) (1).  

Given her stable condition and improving clinical course, she was discharged to follow up with her outpatient provider with recommendation for an anti-phospholipid and hypercoagulability workup.

Daniel J Casey, MSIV. Faraz Jaffer, MD. and Don Leo Pepito, MD.

University of Arizona College of Medicine at South Campus

Tucson, Arizona USA

References

1. LeBlond R, Brown D, DeGowin R. The abdomen, perineum, anus, and rectosigmoid. In: Degowin's Diagnostic Examination. New York, NY: McGraw Hill Medical; 2009: 445-527.
2. Schattner A, Adi M, Kitroser E, Klepfish A. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome. Medicine (Baltimore). 2015 Sep;94(36):e1363. [CrossRef] [PubMed]
3. Cox M, Li Z, Desai V, Brown L, Deshmukh S, Roth CG, Needleman L. Acute nontraumatic splenic infarctions at a tertiary-care center: causes and predisposing factors in 123 patients. Emerg Radiol. 2016 Apr;23(2):155-60. [CrossRef] [PubMed]

Cite as: Casey DJ, Jaffer F, Pepito DL. Medical image of the week: splenic infarction. Southwest J Pulm Crit Care. 2016;13(2):63-4. doi: http://dx.doi.org/10.13175/swjpcc060-16 PDF

August 2016 Imaging Case of the Month

Michael B. Gotway, MD  

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Clinical History: A 47 year-old white man presented with a history of worsening shortness of breath over the past few months. When questioned, the patient indicated that his activity tolerance had probably been slow decreasing over a relatively long period of time, but had become more pronounced recently.

Laboratory data, include white blood cell count and serum chemistries were within normal limits. Oxygen saturation on room air was 93%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal and lateral chest radiography. Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of seven panels)

1. The frontal chest radiograph appears normal
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows abnormally increased lung volumes
4. The frontal chest radiograph shows bilateral linear and reticular abnormalities
5. The frontal chest radiograph shows pneumothorax

Cite as: Gotway MB. August 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(2):54-62. doi: http://dx.doi.org/10.13175/swjpcc072-16 PDF