Multiple Splenic Infarcts Research Articles

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Splenic infarction secondary to probable scrub typhus

A mite‑borne infection, scrub typhus is endemic in India. It causes a myriad of complications with multisystemic involvement like meningoencephalitis, acute respiratory distress syndrome (ARDS), myocarditis and is also known to cause abdominal complications like hepatomegaly, gastrointestinal haemorrhage, acute pancreatitis, and acute renal failure. Among the abdominal organs, splenic involvement is considered to be very rare and the usual presentation in such cases is splenomegaly. Splenic infarcts are a lesser known complication of scrub typhus which has been sparsely reported in the literature. We report a case with a rare presentation of scrub typhus in a 39-year-old male who reported to our hospital with fever and gastrointestinal system related complaints and was ultimately diagnosed to have multiple splenic infarcts secondary to scrub typhus.

An unusual manifestation of scrub typhus presenting with splenic infarct: a case report

Scrub typhus has a wide range of clinical presentation varying from mild symptoms like fever, chills, headaches, myalgias, gastric ulcerations and hepatitis to more fatal conditions like pneumonia and encephalopathy caused by disseminated vasculitis with splenic infarct being a rare complication. We report a case of 50-years old male with scrub typhus who presented as multiple splenic infarcts.

A Case of Adult-Onset Kawasaki Disease in an Adolescent Occurring during the COVID-19 Pandemic

AbstractWe report the occurrence of the adult-onset type of Kawasaki disease (KD) with classic mucocutaneous manifestations of KD, cholestatic liver disease, multiple splenic infarcts, and residual multiple coronary artery dilatations in a previously healthy 14-year-old male adolescent 16 days after having received one dose of the BNT162b2 coronavirus disease 2019 (COVID-19) mRNA vaccine. First, the report serves to highlight the diagnostic challenges of adult-onset KD often resulting in therapeutic delay and the frequently reported occurrence of persistent cardiovascular sequelae. Second, the report emphasizes that the temporal association of KD with the administration of a COVID-19 vaccine will likely be a frequent constellation in the near future, raising questions of a causative association. While there is currently no evidence of such an association in persons above 5 years of age, large-scale vaccination of children below 5 years of age will require close surveillance of vaccine-related adverse events.

IS THE PATENT FORAMEN OVALE AN INNOCENT BYSTANDER OR THE REAL CULPRIT? THE MILLION-DOLLAR QUESTION

IS THE PATENT FORAMEN OVALE AN INNOCENT BYSTANDER OR THE REAL CULPRIT? THE MILLION-DOLLAR QUESTION

INFECTIVE ENDOCARDITIS WITH SPINAL CORD INFARCTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis can present with disseminated septic emboli phenomenon. Neurological complications of disseminated infective endocarditis include spinal epidural abscess. Spinal cord infarction is a very rare complication of infective endocarditis with only two cases previously reported. We present a case with fulminant infective endocarditis with widespread septic emboli and spinal cord infarction. CASE PRESENTATION: 34-year-old male, intravenous drug abuser with recent incarceration presented with five-day history of progressive lower extremity weakness and pain associated with inability to walk, lower back pain, loss of bowel and bladder control, and pleuritic chest pain. Past medical history was significant for recurrent infective endocarditis of tricuspid valve and prosthetic tricuspid valve with recent tricuspid valve repair 6 months ago. Laboratory analysis was remarkable for leukocytosis, microcytic anemia, severe thrombocytopenia, lactic acidosis, and oliguric acute kidney injury requiring emergent hemodialysis. The patient was subsequently intubated for acute respiratory failure with worsening septic shock requiring pressor support. Transthoracic echocardiogram revealed a normal left ventricular ejection fraction. A large 4.1 x 1.6 cm mobile vegetation was noted involving the bioprosthetic tricuspid valve extending into the right ventricle associated with moderate stenosis. Blood cultures were positive for Serratia marcescens. CT chest was significant for bilateral ground-glass opacities, multiple nodular infiltrates, and cystic cavitary lesions representing septic emboli. CT abdomen was significant for splenomegaly with multiple splenic infarcts and bilateral multiple renal cortical infarcts. CT scan of spine ruled out epidural abscess. MRI could not be performed due to presence of epicardial leads. Based on above findings, patient was diagnosed with infective endocarditis with systemic shower of septic emboli to lungs, spleen, and kidneys with high suspicion of spinal cord infarction. Patient was started on empiric antibiotics on admission later adjusted to culture sensitivities. He continued to deteriorate clinically and underwent cardiac arrest within 72 hours of admission and expired. DISCUSSION: Infective endocarditis with septic emboli phenomenon can present with a myriad of clinical features. In the presence of neurological deficits, spinal cord infarction should be high in the differential and managed emergently due to its time-sensitive salvage. However, the probability of complete recovery after spinal infarction is very low; overall mortality in the first month is 25%, with long-term disability in 40-50% requiring wheelchair or chronic bladder catheterization. CONCLUSIONS: Spinal cord infarction is a rare complication of infective endocarditis with disseminated septic emboli phenomenon that requires emergent time-sensitive management with overall high mortality. REFERENCE #1: Kfoury B, Sharma D, Mansour W, Suen P, Abou Yassine A, Chalhoub M. Endocarditis to the Spine: A Rare Cause of Spinal Cord Infarction. Chest. 2017 Oct 1;152(4):A366. REFERENCE #2: Robertson, C.E., et al., Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology, 2012. 78(2): p. 114-21 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Stanislav Ivanov, source=Web Response No relevant relationships by Arsalan Wappi, source=Web Response No relevant relationships by Christopher Wood, source=Web Response

A TICKING TIMEBOMB: FLOATING AORTIC ARCH THROMBUS IN A PATIENT WITH METASTATIC SQUAMOUS CELL CARCINOMA OF THE LUNG

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Thoracic aortic mural thrombi are a rare clinical entity and most patients are asymptomatic before significant embolic events occur(1). There are only a few reported cases and are mostly in patients who presented with complications of peripheral thromboembolism. We report the case of a patient who presented with symptoms of congestive heart failure and was found to have a large floating thoracic aortic thrombus. CASE PRESENTATION: The patient is a 61-year-old female with no prior medical history who presented with shortness of breath on exertion and dry cough of three weeks duration. The patient has an extensive 40 pack-year smoking history. On evaluation, the patient was tachypneic, hypertensive, and was saturating well on room air. Crackles could be heard at the bases of the lungs and there was pitting edema of bilateral lower extremities. Laboratory studies showed a b-type natriuretic peptide level of 1741 pg/mL. A chest X-ray revealed pulmonary edema and bilateral pleural effusions. With a diagnosis of heart failure, gentle diuresis with intravenous furosemide was initiated. An echocardiogram showed global hypokinesis of the left ventricle with a reduced ejection fraction of 25-30%. CT scan of the chest revealed a large 6 x 7 cm necrotic mass in the left lower lung field with mediastinal adenopathy. There was a pulmonary embolus in the posterior basal segment of the left pulmonary artery, originating from the location of the mass. The CT was also significant for an intraluminal polypoid filling defect in the aortic arch with multiple small splenic and left renal infarcts, suggestive of a peripherally embolizing aortic thrombus. The patient was started on anticoagulation with low molecular weight heparin and was recommended to have an aortic arch stent placed to prevent further embolization of the thrombus. However, the patient decided against the procedure. Further biopsy and staging workup of the left lung mass revealed metastatic squamous cell carcinoma. The patient decided against palliative chemotherapy and opted for hospice care. DISCUSSION: Thoracic aortic mural thrombus is the result of disturbances in the Virchow's triad, ie, stasis, hypercoagulability, and endothelial dysfunction. The patient's smoking history, extensive atherosclerosis, malignancy, and left ventricular dysfunction were likely contributing factors. Aortic thrombi are prone to peripheral embolization to sites such as the spleen, kidneys, small bowel, and lower extremities(2). Early diagnosis and prompt management with anticoagulation are key. Endovascular repair with endograft stents is a novel modality of treatment with higher safety, patient acceptability, and a lower rate of peripheral embolization(3). CONCLUSIONS: Thoracic aortic thrombi are an initially silent rare disease condition with potentially fatal complications. Prompt management with anticoagulation and possible endovascular treatment is warranted. REFERENCE #1: Yang P, Li Y, Huang Y, Lu C, Liang W, Hu J. A giant floating thrombus in the ascending aorta: a case report. BMC Surg. 2020 Dec 9;20(1):321 REFERENCE #2: Bukharovich IF, Wever-Pinzon O, Shah A, Todd G, Chaudhry FA, Sherrid MV. Arterial Embolism Caused by Large Mobile Aortic Thrombus in the Absence of Atherosclerosis, Associated with Iron Deficiency Anemia. Echocardiogr Mt Kisco N. 2012 Mar;29(3):369–72. REFERENCE #3: Jamjoom R, Zagzoog MM, Sait S. Outcome of Endovascular Approach for Management of Thoracic Aortic Thrombus. Ann Vasc Surg. 2019 Aug 1;59:307.e7-307.e12. DISCLOSURES: No relevant relationships by Amjad Basheer, source=Web Response No relevant relationships by Rana Prathap Padappayil, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response No relevant relationships by vinit singh, source=Web Response No relevant relationships by Raghu Tiperneni, source=Web Response

Catastrophic Coronavirus Disease COVID Infection Leading to Gangrene of Foot in Peripartum Women.

Introduction:Pregnancy is a physiologically hypercoagulable state and a coronavirus disease 2019 (COVID-19) infection adds to this burden by accentuating the coagulopathy. We report two cases of severe peri-partum COVID infection leading to extremity gangrene secondary to a pro-thrombotic coagulopathy.Case One:A 37-year-old lady, day-2 postpartum, was brought with severe COVID infection & and respiratory failure. She developed progressive gangrene of the foot. A computed tomography (CT) angiogram confirmed the presence of thrombosis of the left external iliac & and common femoral artery. She was managed with catheter- directed thrombolysis and fasciotomy. The dry gangrene of the foot was managed with a Boyd’s amputation. At 1-year follow-up, she is ambulant with a healthy stump.Case Two:A 34-year-old lady, 36 weeks of gestation, presented with fulminant COVID infection with respiratory failure and pulmonary embolus. The lady developed gangrene of the B/L toes. A CT angiogram revealed thrombosis below the popliteal trifurcation in both limbs along with segmental pulmonary thrombo-embolism involving the right lung and multiple splenic infarcts. She succumbed to the overwhelming infection and sepsis.Discussion:The pathogenesis of coagulopathy in pregnant COVID patients is attributed to the hypercoagulable effect, which leads to thrombo-embolisms and limb ischemia following a cytokine storm syndrome in severe infections. To date, this is the first experience detailing distal limb gangrene in fulminant COVID infection in peri-partum women. Although, cases have been reported on distal limb gangrene in severe COVID infection among non-pregnant individuals.Conclusion:A multidisciplinary team must manage COVID infections in the third trimester. A prompt recognition of any forms of lethal coagulopathy and vigilant treatment will prevent loss of life.

Multiple anatomic sites of infarction in a pediatric patient with M. pneumoniae infection, a case report

BackgroundAlthough M. pneumoniae (M. pneumoniae) infections have been associated with various extrapulmonary manifestations, there have been very few documented cases of thrombotic events in pediatrics, and none to our knowledge with such extensive involvement as the patient described here. We aim to contribute to the urgency of discovering the mechanism of the coagulopathy associated with M. pneumoniae infections.Case presentationThis 10-year-old boy was admitted after 2 weeks of fever, sore throat, worsening cough, and progressive neck and back pain. During hospitalization, he developed clots in several different organs: bilateral pulmonary emboli, cardiac vegetations, multiple splenic infarcts, and deep venous thromboses in three of four extremities. He was treated with long-term antibiotics and anticoagulation, and fully recovered.ConclusionsThis is the first case known to us of a child with an extensive number of thrombotic events in multiple anatomic sites associated with M. pneumoniae infection. The mechanism by which M. pneumoniae infection is related to thrombotic events is not fully understood, but there is evidence that the interplay between the coagulation pathways and the complement cascade may be significant. This patient underwent extensive investigation, and was found to have significant coagulopathy, but minimal complement abnormalities. By better understanding the mechanisms involved in complications of M. pneumoniae infection, the clinician can more effectively investigate the progression of this disease saving time, money, morbidity, and mortality.

Dengue Fever Complicated by Sickle Cell Crisis with Multiple Splenic Infarcts

Dengue infections typically present with fever and thrombocytopenia. Although good number of patients improve with supportive care, few can have a fulminant course with multiorgan dysfunction. In endemic zone co-occurring illness like Sickle cell disease can contribute to poor outcome. Various splenic complications of Sickle cell disease include massive splenomegaly with sequestration, large infarcts and abscess requiring splenectomy. We report an interesting case of dengue fever, who developed shock and acute abdomen during hospital stay. Further evaluation revealed multiple splenic infarcts with correlating histopathology and etiological work up including hemoglobin electrophoresis helped in the de novo detection of the underlying sickle cell trait.International Journal of Human and Health Sciences Vol. 05 No. 04 October’21 Page: 519-524

Salmonella paratyphi-induced splenic vein thrombosis: A case report on infrequent cause of acute abdomen

Splenic vein thrombosis and splenic infarction are complications beyond the usual clinical spectrum of paratyphoid fever, and the presentation is rarely described. We report the case of a young female, who presented with high-grade fever and severe left upper quadrant pain. Her blood culture was positive for Salmonella paratyphi A, with Widal test suggesting 4-fold rise in titers. Computed tomography revealed splenic vein thrombosis and multiple splenic infarcts, for which antibiotic and anticoagulation were instituted simultaneously. She had a complete resolution with this management, and anticoagulation was tapered off on subsequent visits.

Severe recurrent Streptobacillus moniliformis endocarditis in a pregnant woman, and review of the literature

BackgroundRat bite fever is a systemic febrile illness caused by infection with the Gram-negative bacillus Streptobacillus moniliformis following a bite, scratch, or contact with excrement. Only 26 cases of native valve endocarditis have been reported to date. We could find no other reports of severe Streptobacillus endocarditis requiring valve replacement in a young, pregnant patient.Case presentationA pregnant patient sought care for right leg pain, fevers, left upper quadrant pain, generalized weakness, fatigue, and inability to bear weight on her right leg. She had a syncopal episode 9 months earlier, resulting in a mandibular fracture and internal fixation hardware. Her pregnancy was complicated by hyperemesis and weight loss. Her pets included a rescued wild bird, a cat, and four rats. Her parents rescued stray cats, and she recalled multiple cat bites and scratches since childhood. She denied injection drug use. Ultrasound indicated a right popliteal artery thrombus. Transesophageal echocardiogram revealed a 2 cm × 0.7 cm vegetation. Angiography demonstrated multiple splenic infarcts and bilateral renal infarcts. She underwent mitral valve repair. The mitral valve Gram stain demonstrated 2+ Gram-negative rods, rare Gram-positive rods, and moderate white blood cells. Propionibacterium spp. was isolated from the mitral valve tissue on Columbia agar incubated anaerobically. Anaerobic and aerobic cultures of the valve tissue on all other broths and agars remained negative at 14 days. Hematoxylin and eosin stains showed a fibro-inflammatory vegetation. Aggregates of rod-shaped bacteria were identified on Warthin Starry/Steiner stain. Bartonella titers were positive for B. henselae IgG 1:256, IgM < 1:20. Brown-Hopps Gram stain, AFB, and GMS stains for bacterial and fungal microorganisms were negative. Broad range bacterial PCR and sequencing of a segment of 16 s rRNA gene of the valve tissue matched to Streptobacillus sp. (genus level) and most closely related to Streptobacillus moniliformis.ConclusionThis case demonstrates diagnostic and therapeutic challenges associated with a relatively uncommon cause of endocarditis. The diagnosis of rat bite fever was delayed due to symptoms of a concomitant pregnancy. Other confounders included possible alternative sources or co-infections with another zoonosis from multiple pets, and an odontogenic source due to presence of exposed jaw hardware.

Fatal Case Of Solid Organ Infarcts In a Case Of Myelodysplastic Syndrome (MDS) With Refractory Anaemia

Myelodysplastic syndrome (MDS) usually presents with cytopenias because of bone marrow failure. Solid organ infarcts in myelodysplastic syndrome (MDS) is rarest complication. We report an elderly male, admitted with complaints of pain abdomen mainly in both flanks and swelling all over the body. Peripheral blood smear, bone marrow aspirate for cytology were suggestive of myelodysplastic syndrome(MDS) with refractory anaemia. Fluorescence in situ hybridization(FISH) were negative for any chromosomal abnormalities. His CECT abdomen was done which revealed hepatosplenomegaly with hyperdense liver with multiple splenic and renal infarcts and patient was treated as a case of MDS with refractory anaemia with solid organ infarcts. Over a period of 3 days, he had Acute Kidney Injury (AKI). Patient succumbed on fifth day.

P171 Catastrophic systemic multiple embolism from a giant atrial mixoma: a case report

Abstract Atrial mixoma represents the most common cardiac tumour. The diagnosis is usually accidental since it is benign and usually asymptomatic. Nevertheless, life-threathening complications such as embolization may seldom occur. In these cases emergent multispecialistic approach is deemed. We describe the case of a 46 year old man without cardiovascular risk factors and whose previous clinical history was not significant. At home, the patient abruptly presented a right hemiplegia, deviation of the buccal commissure to the left and loss of consciousness. On arrival at the emergency department GCS was 5. Routine blood tests, gas analysis and ECG were unremarkable. An urgent CT scan showed a left fronto-parietal subarachnoid hemmorhage. Soon after admission in the stroke unit the patient showed sign of acute limb ischaemia. A high-resolution 3D-angio CT revealed multiple bilateral renal and splenic infarcts and a massive thrombosis of the abdominal aorta below the renal bifurcation, with extensive involvement of the iliac arteries. Unexpectedly, a bulky mass (max diameter 8 cm) was detected in the left atrium. Transthoracic echocardiography confirmed the presence of an irregularly oval (8x3cm) mobile peduncolate mass with fringed edges, suspected for mixoma, with phasic impingement of the mitral valve and protrusion into the left ventricle. Considering the age of the patient and the very early presentation, after Heart Team discussion the patient underwent an urgent embolectomy with Fogarty catheter followed by cardiac surgery for myxoma resection. After full sternotomy, with an interatrial groove approach, a large tumor with myxoid appearance implanted in the left atrial roof was discovered (8 cm maximum diameter). A complete excision of the mass was successfully performed. The macroscopic examination revealed a tumor with a gelatinous and friable surface, very irregular edges and narrow base of implantation, suggestive of atrial myxoma. The day after a CT revealed multiple new ischemic and hemorragic lesions in the left frontal and parietal lobes, in the right occipital lobes, in the cerebellar emispheres, thalamus and hypotalamus and in the mesencephalus. Multiple thrombosis of the main branches of the Willis polygon were detected as well. The patient remained comatous (GCS 3) with bilateral midriasis and was intubated in the intensive care unit. The anatomopathological study confirmed the diagnosis of atrial myxoma. Despite the general belief that atrial mixoma present a benign course, clinicians should carefully consider the possibility of dramatic complications, due to the risk of embolization. High resolution imaging techniques are of pivotal relevance for the diagnosis of the tumor and the complications, in which case emergent surgery may be required. Early surgery could be considered in asymptomatic patients because the evolutionary course and the prognosis can unexpectedly be ominous. Abstract P171 Figure. Multiple embolism from atrial myxoma

P1299 Right sided infective endocarditis with paradoxical embolization

Abstract Background Right sided infective endocarditis (IE) accounts for 5-10% of IE cases, systemic embolization is uncommon and if present it is linked to the presence of shunt or concomitant left sided IE. Clinical presentation A 35-years old gentleman with history of heroin intravenous drug abuse (IV), presented with a history of unexplained fever for two weeks along with exertional dyspnea, productive cough, chest pain and severe left hypochondria pain. On examination he had a blood pressure of 130/80 mmHg, a heart rate of 130 bpm, a temperature of 40oC, elevated jugular venous pressure and a harsh pansystolic murmur over the lower left sternal border. Laboratory results revealed anaemia, leukocytosis elevated ESR and CRP and blood cultures were positive for methicillin-resistant staphylococcus aureus (MRSA), electrocardiography showed sinus tachycardia and abdomen computed tomography scan revealed multiple splenic infarctions. Methods and results 2D&amp;3DTrans-Thoracic Echocardiography (TTE) revealed the presence of an echogenic elongated highly mobile mass measures 2.0 cm in maximum dimension attached to the atrial surface of the anterior tricuspid valve leaflet a long with severe valvular regurgitation. Patent foramen ovale (PFO) was visualized by Color Doppler and right to left shunt was confirmed by contrast study with a complete opacification of the left side. The left ventricle dimensions were normal , there was an evidence of hyokinesis of inter-ventricular septum (IVS) and inferior wall and function was reduced, estimated LVEF = 45%. Hence, coronary angiography was done and revealed normal coronaries. 3D Trans-esophageal Echocardiography(TEE) was done for better visualization of the interatrial septum (IAS), vegetation and to rule out complications. The study confirmed the presence of PFO, there was no concomitant IAS defects, the vegetation is highly mobile and facing the IAS. Accordingly, patient was diagnosed with tricuspid infective endocarditis complicated with paradoxical embolization, anti-biotics were commenced and patient underwent successful tricuspid valve replacement and PFO closure. Discussion Tricuspid valve endocarditis has been linked to IV drug abuse and staphylococcus aureus has been recognized as the most commonly implicated organism. While systemic emboli are rare in right sided IE, our patient represent this uncommon complication. He had multiple splenic infractions and TTE contrast study showed PFO with a high degree of right to left shunt. Coronary embolization was a suspect in our patient as well given the presence of regional wall motion abnormalities involving the left ventricle inferior wall and IVS. Conclusion Echocardiography is a crucial imaging modality in patient with long standing fever and history of IV drug abuse to rule out infective endocarditis. 3D-TEE is of added value along with TTE in better definition of vegetations and detection of infective endocarditis complication. Abstract P1299 Figure. Tricuspid valve infective endocarditis

Spontaneous Retroperitoneal Hemorrhage - A Rare Presentation of Polyarteritis Nodosa: Role of Angiography in Diagnosis and Management

Spontaneous retroperitoneal hemorrhage (RPH) is a rare but serious complication of polyarteritis nodosa (PAN) and must be considered in patients presenting with RPH as their first presentation. Renal infarctions, liver infarctions, and ruptured microaneurysms are all complications of PAN. We present two cases presenting with abdominal and back pain. The first patient’s abdominal computed tomography (CT) scan revealed fractured right kidney with retroperitoneal pericapsular hematoma and multiple hepatic and splenic infarcts. The digital subtraction angiography (DSA) demonstrated large areas of devascularization of the right kidney and right renal arterial wall irregularity with multifocal areas of stenosis, dilatations, and microaneurysms without active extravasation of IV contrast. She was treated conservatively and started on a pulsed dose of steroids and cyclophosphamide. The second patient’s abdominal CT angiography revealed multiple visceral aneurysms and focal areas of stenosis in branches of celiac axis and superior mesentery artery without active contrast extravasation. The DSA demonstrated multifocal areas of irregularity and narrowing in celiac and intrahepatic arteries as well as a 9 mm pseudoaneurysm in the inferior pancreaticoduodenal artery which was embolized with metallic coils. PAN has a vague clinical presentation and is clinically occult. Patients may be diagnosed while getting investigated for some other causes of abdominal pain. The emergency physician and the radiologist should be aware of the findings and should be able to correlate with pathology to prevent life-threatening complications. Angiography plays a crucial role, not only in diagnosis but also in appropriate management.

Beyond HELLP: Peripartum Catastrophic Thromboembolism due to Hereditary Diffuse Gastric Cancer

Peripartum thrombocytopenia and thrombotic events are usually attributable to diseases like Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) and thrombotic thrombocytopenic purpura (TTP). Malignancy is a rare cause and gastric cancer even more unusual. We report the case of a 28-year-old female with undiagnosed hereditary diffuse gastric cancer (HDGC) in the peripartum period initially presenting with nausea and blurry vision at 35 weeks’ gestation. Following cesarean section 1 week later, she developed thrombocytopenia and elevated blood pressure; HELLP was diagnosed. Development of acute kidney injury, decreasing platelet count and anemia lead to consideration of TTP. Despite plasmapheresis she had no improvement, developed respiratory failure and had acute large vessel arterial and venous thrombosis with multiple cerebral, renal, splenic and lower extremity arterial infarctions. Deep venous thrombosis of lower limbs was also seen. She was placed on corticosteroids and anticoagulation. Following extensive workup, vegetations on mitral valve were seen on echocardiography and she was started on antibiotics for endocarditis. She deteriorated into refractory shock, multiple organ failure and died on postpartum day 8. Autopsy done revealed diffuse submucosal gastric adenocarcinoma (linitus plastica). Metastases were present on small bowel, fallopian tubes, ovary and the placenta. Mitral valve had marantic vegetations. Tumor cells showed CDH1 gene mutation. Such a diagnosis in pregnancy is very challenging due to overlapping symptoms leading to misdiagnosis. Here, thromboembolism was malignancy-related and rapid spread probably hormone-associated. The purpose of this report is to highlight the need to warrant investigation for cancer, among workup for other common conditions, for atypical thromboembolism in pregnancy. J Clin Gynecol Obstet. 2018;7(3-4):81-83 doi: https://doi.org/10.14740/jcgo512w

Massive Splenomegaly as Initial Presentation of Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma in western countries and is characterized by aggressive clinical behavior. Primary splenic DLBCL is an extremely rare clinical condition. We present a case of successfully treated HCV who presented with acute abdominal pain and was found to have massive splenmogaly secondary to DLBCL. A 65-y.o. female presented with 1-week history of marked sharp left upper quadrant, non-radiating abdominal pain. She had poor appetite, nausea and 3 episodes of coffee-ground emesis over one day. She denied fever and review of systems was otherwise negative. Her history is significant for recently treated hepatitis C with sofosbuvir/velpatasvir a few months prior to this presentation. Physical exam was only positive for tender splenomegaly. CT abdomen showed massive splenomegaly with multiple new splenic infarcts (image 1). She was noted to have a 3-gram drop in hemoglobin in one month, so EGD was done (image 2,3). Her HCV RNA was undetectable by PCR. BCR/ABL and JAK2 mutations, as well as EBV and CMV serology were all negative. Peripheral blood showed mature B-cells. Lymph node biopsy and bone marrow biopsy were diagnostic for DLBCL. Patient was started on chemotherapy with RCHOP regimen with good response. Tumors of the spleen are rare and are classified into benign and malignant. Primary malignancies are extremely rare, with lymphoma being the most common splenic malignancy. Splenic lymphomas are heterogeneous. They may be primary, arising from the spleen, or secondary, involving the spleen as part of systemic dissemination of a lymphoma that arises elsewhere. As a general rule, isolated presentation with splenomegaly is more common in indolent lymphoma than in aggressive lymphoma. The association between hepatitis C virus (HCV) infection and malignant lymphoma is well documented. For patients with hepatitis C, who subsequently develop splenomegaly, it is important for clinicians to be suspicious for splenic DLBCL and not blame HCV as the only cause of splenomegaly especially if it develops after treating HCV. This case is unique as it presents a very rare initial presentation of DLBCL, which is splenomegaly due to splenic involvement without having any other symptoms or signs of systemic involvement. Physicians should be made aware of this rare presentation to avoid delay in diagnosis that can adversely affect patient morbidity and mortality.1925_A Figure 1. CT abdomen shows massive splenomegaly, with multiple infarcts1925_B Figure 2. EGD shows gastric polyp1925_C Figure 3. EGD shows non-bleeding angioectasia

An 85-Year-Old Man With Recurrent Fever and Multiple Splenic Infarcts.

An 85-Year-Old Man With Recurrent Fever and Multiple Splenic Infarcts.

Sitagliptin induced splenic infarcts

Sitagliptin belongs to the class of dipeptidyl pepti­dase-4 (DPP-4) inhibitors. DPP-4 inhibitors are remark­ably well tolerated oral antihyperglycemic drugs with an adverse effect profile similar to that of placebo. No adverse effects have been reported even with overdose of sitagliptin in suicide attempts. We present here case summary of a 35-year-old female with type 2 diabetes mellitus and major depressive disorder who presented with multiple splenic infarcts after ingestion of sitag­liptin 700 mg and metformin 14 g with suicidal intent. To the best of our knowledge, there are no published reports of splenic infarcts as an adverse event of sit­agliptin. (Clin Diabetol 2017; 6, 6: 215–217)