A 49 y.o. woman with breast cancer and autoimmune hepatitis with cirrhosis and hepatocellular carcinoma presents with abd pain.

what do you notice  on her CT?

Our patient had a splenic infarct. Splenic infarct occurs when one of the branches of the splenic artery is occluded  or there is venous  congestion with ischemia.  The complications include: a ruptured spleen , bleeding, pseudocyst or  abscess.

gross pathology of a splenic infarct.

CAUSES OF SPLENIC INFARCTION

Splenomegaly-  Splenic infarct is more common in hematological disorders associated with splenomegaly like myeloproliferative disorders. Splenomegaly caused by storage diseases like Gaucher’s can also result in infarct.  Probably the most common cause of splenic infarct is sickle cell disease where autosplenectomy occurs over time.

Splenic infections such as mono, cmv, malaria and babesiosis  are associated with splenic infarcts.  Hypercoagulable states such as malignancy , antiphospholipid syndrome  or factor V Leiden  may also result in splenic infarcts. The infarcts can also be embolic  associated with endocarditis or a fib.

Any compromise of the splenic artery can result in infarction including aortic dissection, external compression by a tumor or torsion of the splenic artery

Vasculitis and DIC are also associated with infarcts. In patients with cancer  a “vascular syndrome” has been described in patients receiving angiogenesis inhibitors like bevacizumab. Immediately following initiation of treatment; strokes, MIs , PEs and splenic infarcts have been reported.

Our patient had cancer which is known to cause a hypercoagulable state.  Decreased protein C, protein S, and antithrombin, activation of factor X, and increased platelet catabolism all  have been implicated in thrombogenesis in cancer patients. 

splenic and liver infarcts in a patient with bevacizumab.

In our patient, coagulation studies were normal, embolic disease was ruled out with a normal cardiac echo. Blood cultures showed no growth. It was assumed that her infarct was due to splenomegaly and her malignancies causing a hypercoagulable state.

Malka D, Van den Eynde M, Boige V et al. Splenic infarction and bevacizumab. 2006. Lancet Oncol 7(12)1038.

Rawla P, Vellipuram AR, Bandaru SS, Raj JP Splenic infarct and pulmonary embolism as a rare manifestation of CMV infection. 2017 Case Reports in Hematology  1850821.

Breuer C, Janssen G, et al. Splenic infarction in a patient  with hereditary spherocytosis, protein C deficiency and acute infectious mono. 2008 Eur J  Pediatr 167(12) 1449-52.

Frippiate F, Donckier J, Vandenbossche P , et al. Splenic infarctin report of three cases of atherosclerotic embolization originating in the aorta and retrospective study of 64 caes. 1996. Acta Clin Belg. 51(6) 395-402.