What are the clinical manifestations of splenic disease?

Clinical Manifestations of Splenic Disease

Splenic problems present with a spectrum of symptoms ranging from asymptomatic incidental findings to life-threatening acute abdomen, with left upper quadrant pain, fever, and splenomegaly forming the classic triad when symptoms are present.

Acute Splenic Conditions

Splenic Trauma and Infarction

• Left upper quadrant pain is the most common presenting symptom, often accompanied by referred left shoulder pain (Kehr's sign) in adolescents and adults 1
• Fever and chills occur in approximately 70% of patients with embolic splenic infarction 2
• Abdominal tenderness with a palpable, tender enlarged spleen is characteristic of splenic abscess 3
• In neonates and young infants, splenic injury may present only as shock, abdominal rigidity, or altered mental status without localizing signs 1

Hemodynamic Manifestations

• Hypovolemic shock can develop from splenic rupture or severe trauma, manifesting as tachycardia, hypotension, and decreased mental status 1
• Signs of effective resuscitation include reduction of heart rate, improved mental status, return of peripheral pulses and normal skin color, increased blood pressure, and urinary output 1

Chronic Splenic Conditions

Splenomegaly Presentations

• Fatigue, weight loss, and malaise are common constitutional symptoms when splenomegaly develops from chronic conditions like chronic myeloid leukemia 1
• Left upper quadrant fullness or pain from mass effect of an enlarged spleen 1
• Clinical splenomegaly is detectable in only 30-40% of cases and is not a reliable sign of underlying splenic pathology 1, 4

Hematologic Manifestations

• Bleeding can occur from thrombocytopenia or platelet dysfunction 1
• Thrombosis may result from marked thrombocytosis or leukocytosis 1
• Anemia symptoms including pallor and fatigue 1

Rare but Important Presentations

• Leukostatic symptoms (priapism, dyspnea, drowsiness, loss of coordination, confusion) are uncommon even with white blood cell counts exceeding 100 × 10⁹/L 1
• Gouty arthritis from elevated uric acid levels 1
• Retinal hemorrhages and upper gastrointestinal ulceration from elevated histamine levels due to basophilia 1

Infectious Complications

Splenic Abscess

• Persistent or recurrent fever despite appropriate antibiotic therapy is the hallmark of progression from infarction to abscess 4, 5
• Recurrent bacteremia with positive blood cultures, particularly with Staphylococcus aureus or Streptococcus viridans 5, 6
• Sepsis with hemodynamic instability occurs in approximately 50% of splenic abscess cases at presentation 3

Asymptomatic Presentations

• Approximately 50% of patients with chronic myeloid leukemia are asymptomatic at diagnosis, with splenic involvement discovered incidentally on blood tests 1
• 31% of patients with splenic infarction are completely asymptomatic, particularly those with nonmalignant hematologic conditions (55% asymptomatic) 2

Functional Hyposplenism

• Blood film findings showing Heinz bodies and Howell-Jolly bodies indicate splenic dysfunction 1
• May occur secondary to sickle cell anemia, thalassemia major, essential thrombocythemia, lymphoproliferative diseases, celiac disease, inflammatory bowel disease, and dermatitis herpetiformis 1
• Increased susceptibility to infections from encapsulated organisms, with children under 5 years having infection rates exceeding 10% 1

Critical Pitfalls to Avoid

• Do not rely on the absence of splenomegaly to rule out splenic pathology, as it is present in only 30-40% of cases 1, 4
• Persistent fever after initial treatment should always prompt re-imaging to evaluate for abscess formation rather than assuming treatment failure of the primary condition 4, 5
• In patients with known hematologic or thromboembolic conditions, any left upper quadrant pain with fever should raise immediate suspicion for splenic infarction or abscess 2
• Wandering spleen can present with recurrent episodes of abdominal pain since childhood and may be mistaken for other chronic abdominal conditions 7