What are the signs and symptoms of splenic infarction?

Signs and Symptoms of Splenic Infarction

Splenic infarction presents with left upper quadrant abdominal pain in approximately 70-80% of cases, though a substantial minority (20-31%) remain completely asymptomatic, making clinical diagnosis challenging. 1, 2, 3

Clinical Presentation

Primary Symptoms

• Left upper quadrant or left flank pain is the most common presenting symptom, occurring in 70-80% of patients 1, 3
• Fever and chills are present in approximately 36-70% of cases, particularly common in patients with embolic etiologies (70%) 2, 4
• Constitutional symptoms including malaise and generalized weakness may accompany the acute presentation 4
• Asymptomatic presentation occurs in 20-31% of patients, often discovered incidentally on imaging performed for other reasons 2, 5

Physical Examination Findings

• Left upper quadrant tenderness is the most common physical finding, present in 35-36% of patients 2, 3
• Peritoneal friction rub over the spleen, while classically described by Osler, is rarely encountered in contemporary practice 2
• Splenomegaly may be palpable depending on the underlying etiology and extent of infarction 6
• Absence of localized signs occurs in approximately 31% of cases, making physical examination unreliable as a sole diagnostic tool 2

Laboratory Abnormalities

Hematologic Markers

• Leukocytosis with neutrophilia is common, present in 56-75% of cases, with a concurrent decrease in lymphocyte counts 1, 2
• Anemia is frequently observed in patients with splenic infarction 1
• Thrombocytosis may be present, particularly in patients with underlying hematologic malignancies 7

Biochemical Markers

• Markedly elevated lactate dehydrogenase (LDH) is present in 71% of cases and serves as a useful diagnostic marker 1, 2
• Elevated C-reactive protein (CRP) is remarkably increased in most patients 1
• Hypoalbuminemia is commonly observed 1
• Liver dysfunction with elevated transaminases may be present 1

Coagulation Abnormalities

• Decreased fibrinogen levels are characteristic findings 1
• Markedly elevated D-dimer is consistently observed 1
• Prolonged activated partial thromboplastin time may be present and correlates with worse prognosis 1

Clinical Context and Risk Factors

Common Underlying Conditions

• Hematologic malignancies account for a significant proportion of cases (33-59% in various series), including chronic myeloid leukemia, lymphoma, and other myeloproliferative disorders 1, 7, 4
• Cardioembolic sources including atrial fibrillation (22%) and intracardiac thrombus are frequent etiologies 1, 2
• Infections including bacterial endocarditis (though less common than historically described) and COVID-19 (increasingly recognized) 1, 5
• Solid malignancies with metastatic potential (melanoma, breast, lung, ovarian cancer) 6, 5

Prognostic Indicators

Laboratory parameters that predict mortality include: leukocytosis, decreased lymphocytes, prolonged aPTT, decreased fibrinogen, elevated transaminases, elevated LDH, and elevated blood urea nitrogen 1

Overall mortality in contemporary series ranges from 5-33%, with one-third of patients dying in recent cohorts 1, 4

Diagnostic Imaging Characteristics

• Contrast-enhanced CT scan is the gold standard, demonstrating wedge-shaped or focal hypodense areas in the spleen 6, 4, 3
• Ultrasound is diagnostic in only 18% of cases and should not be relied upon for definitive diagnosis 3
• Doppler ultrasound can assess splenic vascularization but has limited sensitivity 8

Critical Clinical Pitfalls

• Do not dismiss the diagnosis in asymptomatic patients—nearly one-third have no localizing symptoms, and splenic infarction may be the presenting sign of serious underlying disease (bacterial endocarditis, hematologic malignancy, or thromboembolic disorder) in 17-22% of cases 2, 3
• Fever without abdominal pain should still prompt consideration of splenic infarction, particularly in patients with known embolic risk factors 2, 4
• Single infarcts are more likely to present with fever (63%) and leukocytosis compared to multiple infarcts 2
• Surgical complications including splenic abscess and rupture can occur and require vigilant monitoring 4