Splenic Infarction in COVID-19 Patients: A Rare and Uncommon Complication

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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].

Recent research studies have shed light on the increased risk of thromboembolism, both venous and arterial, in COVID-19 patients, creating a prothrombotic state [2-4]. However, a lesser-known complication is splenic infarction, a rare condition with limited documented cases in the context of COVID-19 [5].

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:


Methods

To investigate this rare occurrence of splenic infarction in COVID-19 patients, we conducted a systematic literature search on PubMed to identify relevant case reports for literature review.

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.

Further research is needed to enhance our knowledge of the underlying mechanisms and refine diagnostic and treatment approaches for splenic infarction in the context of COVID-19.


reference link : www.infezmed.it/media/journal/Vol_31_4_2023_15.pdf

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