The coronavirus disease (COVID-19) outbreak, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to a global pandemic, resulting in a significant number of fatalities and hospital admissions worldwide. While the majority of COVID-19 cases are categorized as mild, severe cases have been associated with respiratory failure, septic shock, and multiple organ dysfunction [1].
In this article, we present a case series of splenic infarction in COVID-19 patients that occurred between October 10, 2020, and January 10, 2021, at a tertiary care center. This retrospective study provides detailed insights into this uncommon complication, emphasizing the need to understand potential COVID-19-related complications.
TABLE 1 – Splenic Infarction: A Deep Dive
Splenic infarction, the death of spleen tissue due to compromised blood flow, is a potentially serious yet often under-recognized condition. This comprehensive guide delves into the complexities of this disease, exploring its causes, symptoms, diagnosis, treatment, and potential complications.
Pathogenesis:
- Vascular Occlusion: The culprit behind splenic infarction is blockage of the splenic artery or its branches. This can occur through various mechanisms:
- Thrombosis: Blood clots formed within the artery itself due to conditions like atherosclerosis, sickle cell disease, or vasculitis.
- Embolism: Clots or debris dislodged from elsewhere in the body (e.g., heart, aorta) and travel to the splenic artery, blocking its flow.
- Vascular compression: External pressure on the artery from tumors, pancreatitis, or other causes can restrict blood supply.
- Consequences of Occlusion: Blockage leads to ischemia (reduced blood flow), depriving the spleen of oxygen and vital nutrients. This triggers a cascade of cellular events:
- Apoptosis: Programmed cell death in affected tissue.
- Inflammation: Recruitment of immune cells to the injured area.
- Fibrosis: Scarring and tissue repair, sometimes leading to splenic adhesions.
Clinical Presentation:
Symptoms of splenic infarction vary depending on the size and location of the infarct. Some patients may be asymptomatic, while others experience:
- Abdominal pain: Left upper quadrant, often sudden and sharp, worsening with movement.
- Fever: Can range from mild to high, often accompanied by chills.
- Nausea and vomiting: Common, reflecting the inflammatory response and discomfort.
- Left shoulder pain: Kehr’s sign, due to diaphragmatic irritation from the infarcted spleen.
- Other symptoms: Fatigue, sweating, loss of appetite, weight loss.
Diagnosis:
Early diagnosis of splenic infarction is crucial for optimal outcomes. Imaging plays a key role:
- CT scan: The gold standard, providing detailed visualization of the infarct size, location, and presence of complications.
- MRI scan: Offers superior tissue differentiation and can be helpful in specific cases.
- Ultrasound: Less invasive option but may not be as sensitive for small infarcts.
Laboratory tests, like complete blood count and inflammatory markers, can support the diagnosis but are not specific.
Treatment:
Management strategies for splenic infarction depend on the severity and cause:
- Conservative approach: Most small, uncomplicated infarcts can be managed non-operatively with pain management, supportive care, and close monitoring for complications.
- Surgery: Splenectomy, complete or partial removal of the spleen, may be necessary in cases of:
- Large infarcts with ongoing bleeding or severe pain.
- Abscess formation within the infarct.
- Underlying conditions requiring splenectomy (e.g., hypersplenism).
- Thrombolytic therapy: Dissolving blood clots with medications is rarely used due to potential complications like bleeding.
Complications:
Splenic infarction can lead to various complications, including:
- Abscess formation: Requires surgical drainage and antibiotics.
- Bleeding: May occur within the infarcted area or into the peritoneal cavity, necessitating emergency surgery.
- Splenic rupture: Rare but potentially life-threatening, requiring immediate surgery.
- Thromboembolic events: Pulmonary embolism or deep vein thrombosis can occur, necessitating anticoagulation therapy.
Prognosis:
The prognosis for splenic infarction depends on several factors, including:
- Size and location of the infarct.
- Underlying medical conditions.
- Promptness of diagnosis and treatment.
Most patients recover well with conservative management. However, complications can increase mortality and morbidity.
Additional Resources:
- American College of Gastroenterology: http://www.emdocs.net/splenic-infarction-ed-presentation-evaluation-and-management/
- Mayo Clinic: https://www.mayoclinicproceedings.org/article/S0025-6196%2812%2962638-X/fulltext
- National Center for Biotechnology Information: https://www.ncbi.nlm.nih.gov/books/NBK430902/
Methods
Case Reports
In our retrospective case series, we examined six cases of splenic infarction in COVID-19 patients admitted to a tertiary care center during the specified period. All patients had confirmed COVID-19 diagnoses through nasopharyngeal swab or Computed Tomography (CT) scan, and splenic infarct was further confirmed by abdominal CT scan.
Case 1: A 35-year-old male presented with fever, chills, rigor, abdominal pain, and maculo-papular rash. Laboratory results indicated low hemoglobin (Hb) of 14.1 gm%, a white blood cell (WBC) count of 2900, platelet (PLT) count of 50000, and normal D-dimer and fibrin degradation product (FDP) levels. A positive Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test confirmed COVID-19. A CT scan revealed splenic laceration with hemorrhage. The patient received packed red blood cells (RBCs) transfusion and symptomatic management.
Case 2: A 67-year-old male with hypertension presented with moderate abdominal pain for 12 days. Laboratory results showed normal Hb, WBC, and PLT levels but elevated D-dimer. CT scan revealed splenic infarction with a thrombus in the splenic artery. The patient was treated with enoxaparin and later switched to oral rivaroxaban.
Case 3: A 29-year-old female with sickle cell trait presented with various symptoms. Laboratory results indicated anemia, high WBC count, elevated D-dimer, and FDP levels. CT scan revealed splenic infarct and lung abnormalities. The patient received hydroxychloroquine, tocilizumab, and continuous heparin infusion in the ICU.
Case 4: A 58-year-old male with dyslipidemia presented with respiratory symptoms and elevated D-dimer. CT angiography showed arterial occlusions. Treatment included hydroxychloroquine, azithromycin, anakinra, and low-molecular-weight heparin.
Case 5: A 57-year-old male with diabetes mellitus presented with fever, cough, and dyspnea. Laboratory results showed an elevated D-dimer. CT scan revealed intra-aortic thrombi and splenic infarct. Treatment included hydroxychloroquine, antibiotics, low-molecular-weight heparin, tocilizumab, and oxygen therapy.
Case 6: A 70-year-old male with multiple comorbidities presented with various symptoms. Laboratory results indicated anemia and elevated D-dimer. CT scan revealed splenic infarct and a hematoma. Treatment included enoxaparin, dexamethasone, remdesivir, and radiological embolization.
Discussion
- Thrombotic Complications in COVID-19: COVID-19 has been associated with a heightened risk of thromboembolism, both venous and arterial, especially in severe cases. A recent meta-analysis revealed that COVID-19 patients who developed thromboembolism had a significantly higher risk of mortality, emphasizing the critical importance of monitoring and managing clotting issues in these patients [6].
- Role of Antiphospholipid Antibodies (aPL): The presence of antiphospholipid antibodies (aPL) in COVID-19 patients has raised questions about their potential contribution to thrombotic complications. A study involving 250 COVID-19 patients found that 58% tested positive for aPL, with lupus anticoagulant (LA) being the most prevalent. However, the transient or persistent nature of aPL antibodies in these patients remains unclear [8]. The presence of aPL may contribute to the hypercoagulable state observed in COVID-19, potentially playing a role in complications such as splenic infarction.
- Arterial and Venous Thrombotic Events: COVID-19 can lead to both arterial and venous thrombotic complications. Critically ill COVID-19 patients have been reported to experience thrombotic complications despite systemic thromboprophylaxis. These events include venous thromboembolisms (27%) and arterial thrombotic events (4%) [5].
- Abdominal Imaging in COVID-19 Patients: Abdominal symptoms are not the primary focus in COVID-19 patients, with respiratory symptoms taking precedence. However, chest CT scans can identify incidental or symptomatic splenic infarctions. Autopsy findings have suggested a higher prevalence of splenic involvement due to COVID-19-related hypercoagulability than reported. It is important to consider vascular complications, including splenic infarction, in patients presenting with acute abdominal pain, irrespective of age [9].
- Clinical Characteristics of Splenic Infarction: Splenic infarction is a rare condition in the general population, with underlying hematological conditions being common risk factors. COVID-19 patients with splenic infarction may present with left upper quadrant tenderness, fevers, nausea, vomiting, and rarely, constipation. Abdominal pain in COVID-19 patients should raise suspicion of vascular involvement [11].
- Imaging Characteristics and Diagnosis: Distinct imaging characteristics are observed during various stages of splenic infarction, from edema and inflammation in the acute phase to more defined lesions in the chronic phase. Contrast-enhanced CT is the preferred diagnostic tool, allowing for the detection of infarctions and thrombosis. Ultrasound can also be used for follow-up, particularly in ICU patients, when performed by an experienced sonographer [12-15].
- Management of Splenic Infarction: The primary approach to managing splenic infarction is conservative, addressing the underlying cause. Data from non-COVID-19 patients suggests that most infarcts resolve without complications. Surgical intervention or splenectomy is rarely required [16].
- Treatment Approaches in COVID-19 Patients: The treatment of thrombotic events in COVID-19 patients remains a subject of debate. Empirical anticoagulation with therapeutic heparin or LMWH is considered in severe cases, especially when the SIC score is ≥4 or D-dimer levels are significantly elevated [17]. However, the management of thrombotic complications should be tailored to the individual patient’s clinical presentation and underlying conditions.
- Multidisciplinary Approach and Further Research: The presented case series underscores the need for a multidisciplinary approach to manage splenic infarction in COVID-19 patients, given the variations in clinical characteristics and outcomes. Further research is essential to elucidate the precise pathophysiological mechanisms of splenic infarction in COVID-19 and optimize diagnostic and treatment strategies. This includes investigating the interaction between the SARS-CoV-2 virus and the coagulation system within the spleen and developing standardized criteria, imaging protocols, or biomarkers for more accurate diagnosis.
In conclusion, splenic infarction is a rare but significant complication in COVID-19 patients, with a multifaceted clinical presentation and varying outcomes. Recognizing and understanding this complication is crucial for healthcare providers to ensure timely diagnosis and appropriate management.
reference link : www.infezmed.it/media/journal/Vol_31_4_2023_15.pdf
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