Multiple Splenic Infarcts Research Articles

Polycythemia Vera (PV) Complicated by Late Diagnosis of Multiple Splenic Infarcts: A Case Report

Polycythemia vera (PV) is a chronic myeloproliferative tumor where bone marrow makes more red blood cells and other bone marrow cells. Many patients initially are asymptomatic, however, other patients may develop symptoms and complications of this disease later on. One of the PV complications is developing thrombosis in different sites, one of these sites is splenic vessels causing splenic infarction. Here we are describing a JAK2 positive PV case who presented with vague abdominal pain and diagnosed by CT to have splenic infarction, and was treated medically without going to surgical options. In conclusion, splenic infarction is a rare and unique complication of PV. Early diagnosis is paramount to prevent complications and a team approach is highly recommended for the best outcomes.

Unusual Presentation of Diffuse Large B-Cell Lymphoma With Splenic Infarcts.

A 67-year-old man presented with a 3-day history of abdominal pain, fever, and significant weight loss over 2 months. Physical examination revealed left upper quadrant tenderness, hepatomegaly, splenomegaly, and bilateral pitting edema but peripheral lymphadenopathy was absent. Laboratory tests showed anemia, thrombocytopenia, elevated prothrombin time (PT), partial thromboplastin time (PTT), and increased lactate dehydrogenase (LDH). PTT was corrected completely in mixing study. Further workup for the cause of coagulopathy revealed decreased levels of all clotting factors except factor VIII and increase fibrinogen levels, which ruled out disseminated intravascular coagulation (DIC). Flow cytometry of peripheral blood was normal. Contrast-enhanced computed tomography (CECT) revealed splenomegaly with multiple splenic infarcts without any mediastinal or intraabdominal lymphadenopathy. Further investigations for infective endocarditis (blood cultures and transthoracic echocardiography) and autoimmune disorders (ANA, dsDNA, RA factors) were negative. The patient received treatment for sepsis empirically without any significant clinical improvement. The diagnosis remained unclear despite extensive workup and liver biopsy was conducted due to high suspicion of granulomatous diseases. However, the liver biopsy revealed high-grade diffuse large B-cell lymphoma (DLBCL). Unfortunately, patient died shortly after the diagnosis. Here we report a case of high-grade DLBCL with hepatosplenomegaly and splenic infarcts in the absence of any lymphadenopathy or focal lesions. This case highlights the fact that unusually lymphoma can present in the absence of lymphadenopathy or mass lesion mimicking autoimmune and granulomatous disorders. The diagnosis in these cases can only be made on histology, and hence the threshold for biopsy should be low in patients with unclear presentations and multiorgan involvement.

Multiple splenic infarctions in a malagasy patient whith both southeast asian ovalocytosis and a sickle cell trait

Introduction: Southeast Asian Ovalocytosis is a dominantly inherited pathology due to a red blood cell membrane abnormal band 3 protein which is prevalent in Southeast Asia. It is associated with no clinical manifestations or induced hemolytic anemia. Case Report: We report herein a case of a 30 years old patient with both Southeast Asian Ovalocytosis and sickle cell trait who had three splenic infarctions without hypoxic situation. Since the last episode, there was no anemia and reticulocyte count and bilirubin reached normal levels. Conclusion: This abnormal band 3 protein lead to a red blood cell deshydratation which could explain polymerization of HbS and clinical manifestations. Only one case of a retinal stroke in a patient from the Comoros Islands with both Southeast Asian Ovalocytosis and a sickle cell trait has been previously reported in 2009. Splenic infarctions could be therefore another clinical manifestation of this association.

Multiple Pulmonary and Splenic Infarcts Triggered by Acute CMV Infection and Transient Double Antiphospholipid Antibody Positivity in a Patient Carrier for JAK-2 Mutation

The co-existence of inherited thrombophilia with antiphospholipid antibody (aPL) positivity is not uncommon. This association does not overrule the diagnosis of antiphospholipid syndrome. Infection may present together with transient aPL positivity, usually aCL-IgM isotype. Thus certain infections, virus particularly, may increase “per se” thrombotic risk. Herein, we communicate the case of a 29-year-old man who sought medical attention because of a ten days course left-side abdominal pain, cough, fever, fatigue, arthralgia and mild dyspnoea. The patient was diagnosed of multiple pulmonary and splenic infarcts. Interestingly, laboratory results showed the presence of JAK2- V617F mutation, positive CMV serology, first IgM and IgG further, as well as LA test and aCL-IgM transiently but recurrently positive. The role played by these aPL transiently positive antibodies – laboratory category I – as a trigger in the development of this thrombotic diathesis is being discussed.

Multiple splenic infarctions with a rare etiology

Malaria is the most common parasitic infection in tropical countries such as India, and it causing a major economic burden on the Asian and African countries. Splenic complication is common in Plasmodium falciparum infection, but splenic infarction itself is a rare clinical entity in P. falciparum infection. Herein, we are presenting a case report of an 18-year-old male patient who presented to the department of medicine with a complaint of pain abdomen. On the next day of admission, the patient had complained of fever with chills and rigor. Routine blood investigations including peripheral smear examination for malarial parasites were sent. Contrast-enhanced computed tomography (CECT) of the abdomen was performed to diagnose the cause of abdominal pain after the findings of infarction in ultrasonography. CECT showed multiple infarctions of spleen and peripheral blood film showed ring forms of P. falciparum. Hence, we should always rule out splenic complication in cases of malaria which present with fever and left hypochondrium pain.

An unusual presentation of extra-hepatic portal venous obstruction

A 13-year-old girl presented with short duration of fever, left upper abdominal pain and massive tender splenomegaly. There was no evidence of liver dysfunction or significant history. Evaluation revealed multiple splenic infarcts with portal vein thrombosis. She developed splenic abscess and was managed conservatively with percutaneous drainage and antibiotics.

Acute Brucellosis with Splenic Infarcts: A Case Report from a Tertiary Care Hospital in Saudi Arabia.

Splenic infarction is an extremely rare and unique presentation of brucellosis. Only few cases have been reported worldwide. We here report a case of a young man, presenting with acute onset of fever, left hypochondial pain, and vomiting. Further evaluation revealed multiple splenic infarcts and positive blood culture for brucellosis despite negative transesophageal echocardiography for endocarditis. Significant improvement in clinical symptoms and splenic lesions was achieved after six weeks of combination therapy against brucellosis.

Splenic Artery Pseudoaneurysm Presenting as Massive Hematemesis: A Diagnostic Dilemma

Introduction. Splenic artery Pseudoaneurysm, a complication of chronic pancreatitis, presenting as massive hematemesis is a rare presentation. Case Report. We present a case of 38-year-old male admitted with chief complaints of pain in the upper abdomen and massive hematemesis for the last 15 days. On examination there was severe pallor. On investigating the patient, Hb was 4.0 gm/dL, upper GI endoscopy revealed a leiomyoma in fundus of stomach, and EUS Doppler also supported the UGI findings. On further investigation of the patient, CECT of the abdomen revealed a possibility of distal pancreatic carcinoma encasing splenic vessels and infiltrating the adjacent structure. FNA taken at the time of EUS was consistent with inflammatory pathology. Triple phase CT of the abdomen revealed a splenic artery pseudoaneurysm with multiple splenic infarcts. After resuscitation we planned an emergency laparotomy; splenic artery pseudoaneurysm densely adherent to adjacent structures and associated with distal pancreatic necrosis was found. We performed splenectomy with repair of the defect in the stomach wall and necrosectomy. Postoperative course was uneventful and patient was discharged on day 8. Conclusion. Pseudoaneurysm can be at times a very difficult situation to manage; options available are either catheter embolisation if patient is vitally stable, or otherwise, exploration.

Spontaneous celiac artery dissection

Spontaneous celiac artery (CA) dissection is an uncommon cause of acute abdominal pain, accounting for 4% of visceral artery dissections and aneurysms, with the majority of symptomatic visceral artery dissections involving the splenic, hepatic, and superior mesenteric arteries.1,2 Despite a recent increase in the frequency of diagnosis of CA dissection with the use of advanced imaging modalities, its pathogenesis and natural history remain unclear.3 Approximately half of CA dissections are symptomatic, presenting most commonly with acute abdominal pain and unremarkable physical examination and laboratory findings.3,4 A 54-year-old man with a history of hypertension and no recent trauma presented with 6 hours of severe epigastric pain with transient radiation to the back. An initial abdominal computed tomography (CT) angiogram demonstrated a CA aneurysm with an intimal flap extending from the distal celiac artery to the trifurcation (Panels A and B) and a thrombus nearly occluding the splenic artery (Panel C). Hemorrhage was noted in the left anterior pararenal space, and multiple splenic infarctions were present. Repeat imaging 14 hours after presentation showed CA dissection with 90% stenosis at the origin of the common hepatic and

Identification of Splenic Infarction by Emergency Department Ultrasound

BackgroundSplenic rupture or infarction can occur secondary to acute infectious mononucleosis. Patients with abdominal pain and known or suspected infectious mononucleosis mandate evaluation for these complications, which can have significant morbidity or mortality. Case ReportAn 18-year old man presented to the emergency department (ED) with a 2-day history of left upper quadrant abdominal pain. He had been diagnosed with mononucleosis 4 days before his ED presentation. Physical examination was notable for focal left upper quadrant tenderness. The treating physician's principal diagnostic considerations were splenic rupture or infarction secondary to mononucleosis. Point-of-care ultrasound was performed by the emergency physician, demonstrating multiple hypoechoic areas in the splenic parenchyma with absent Doppler flow, consistent with multiple splenic infarcts. The patient was admitted for observation, managed conservatively, and had an uneventful course. ConclusionEmergency ultrasound of the spleen can allow rapid diagnosis of splenic infarction and exclusion of splenic rupture in a patient at risk for splenic pathology.

Fungal endocarditis with central and peripheral embolization: Case report

A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation, cerebral infarcts and right common iliac artery pseudoaneurysm. While awaiting transfer to the cardiothoracic surgery department, the patient presented acute arterial ischemia of the left leg, and distal left patellofemoral embolectomy was successfully performed. The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve. After 14 days he was referred for vascular surgery, where the four-month hospitalization was complicated by left leg amputation. Four months after discharge, the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization. He was transferred to the cardiothoracic surgery department, but suffered cardiac arrest before surgical intervention.

Endocardite fúngica com embolização central e periférica: um caso clínico

A 50-year-old man with a history of drug addiction was admitted to the cardiology department for aortic valve fungal endocarditis complicated by severe aortic regurgitation, cerebral infarcts and right common iliac artery pseudoaneurysm. While awaiting transfer to the cardiothoracic surgery department, the patient presented acute arterial ischemia of the left leg, and distal left patellofemoral embolectomy was successfully performed. The patient was then transferred to the cardiothoracic center and the aortic valve was replaced by a bioprosthetic valve. After fourteen days he was referred for vascular surgery, where the four-month hospitalization was complicated by left leg amputation. Four months after discharge, the patient was admitted to the emergency department for recurrent fungal endocarditis complicated by multiple renal and splenic infarcts and celiac trunk embolization. He was transferred to the cardiothoracic surgery department, but suffered cardiac arrest before surgical intervention.

A Case of Symptomatic Left Ventricular Diverticulum

CASE OF SYMPTOMATIC left ventricular diverticulum is presented. This rare congenital cardiac anomaly is reported infrequently in the literature, and the authors report the presentation, various diagnostic modalities available to identify such a lesion, and treatment considerations. CASE REPORT An otherwise healthy 25-year-old woman with a strong family history of premature coronary artery disease presented to an outside hospital on 2 occasions during the same week with complaints of left upper-quadrant abdominal pain. She was diagnosed initially with gastroenteritis and discharged. The following day the patient’s symptoms intensified, and she returned to the emergency department. A computed tomography scan of the abdomen revealed multiple splenic infarcts and an undefined left ventricular cardiac abnormality. She subsequently underwent transthoracic echocardiographic imaging, which revealed an outpouching of the left ventricular apex. After initiating a heparin infusion, she was transferred to the authors’ institution for further workup and treatment. Cardiac catheterization with left ventriculography (LVG) showed a prominent trabeculation in the left ventricular apex containing a thinwalled fenestrated tissue membrane. The left ventricular ejection fraction was noted to be 55% and the coronary arteriogram was unremarkable. Because findings were consistent with either a left ventricular aneurysm or congenital diverticulum and the patient had a history of embolic complications, surgical resection was recommended. In the operating room, transesophageal echocardiography (TEE) showed an anterior apical diverticulum with diastolic inflow and systolic outflow (Figs 1 and 2 and Videos 1 and 2 [supplementary videos are available online]). Further findings were significant for a patent foramen ovale (PFO) and mild mitral insufficiency. No evidence of thrombi was seen. Diverticular contraction and systolic flow into the left ventricle were seen in the midesophageal 4-chamber and transgastric short- and long-axis views using 2-dimensional, M-mode, and color-flow Doppler imaging (Fig 3 and Videos 1 and 2). The diverticulum was further localized with epicardial echocardiographic imaging and subsequently dissected. Gross inspection revealed a thin fenestrated tissue membrane within the diverticular cavity in addition to a diverticular wall that appeared to be composed of the epicardium, myocardium, and endocardium. The muscular diverticulum and intercavitary membrane were resected, and the PFO was closed. At the conclusion of the procedure, TEE showed complete elimination of the diverticular space and membrane without evidence of flow across the PFO. Surgical pathology revealed cardiac-type muscle with mild fiber size variation, which is consistent with the diagnosis of a left ventricular diverticulum. The patient’s postoperative course was without complication and she was discharged on postoperative day 5.

Multiple splenic infarctions due to septic embolization in a patient supported with Berlin Heart-EXCOR biventricular assist device

Patients awaiting cardiac transplantation often require ventricular assist devices (VADs) due to instable circulatory condition. Device-related infections remain the 'Achilles heel' of mechanical circulatory support and wound complications after VAD placement are a formidable challenge to surgeons. Up to 25% of deaths in VAD patients are due to systemic sepsis, which occurs in 11-26% of patients and bacteria that are common pathogens including Staphylococcus, Pseudomonas, Enterococcus, and Candida. Sepsis, infection of implanted pump components, and infections of percutaneous drivelines continue to limit survival. The Berlin Heart-EXCOR VAD is a para-corporeal pulsatile system that has been successful in patients with severe biventricular dysfunction. We report a case of a 35-year-old male suffering from a postischemic cardiomyopathy who received an EXCOR biventricular assist device as a bridge to transplant. During the assistance the patient developed concomitant methicillin-resistant Staphylococcus aureus infection of implanted pump components which was resistant to conventional therapy. The patient developed sepsis with splenic infarctions due to septic embolization which was successfully treated with a heart transplant. In some extreme cases of VAD infections, such as this, the only therapeutic option is transplantation or device replacement.

Polyarteritis nodosa of the spleen

Background: A 64-year-old male presented with pain in his right lower leg and progressive swelling of the right ankle, without history of previous trauma. Further anamnesis revealed fever, anorexia and weight loss over the past few weeks. Laboratory results showed increased inflammatory parameters (CRP 203 mg/l). A lower extremity ultrasonographic examination ruled out deep venous thrombosis. A contrast-enhanced CT scan of the abdomen revealed multiple splenic infarctions.

Treatment with argatroban in one haemodialysed patient with a heparin-induced thrombocytopenia and thrombotic complications

Heparin-induced thrombocytopenia (HIT) is an uncommon but severe immunologic adverse effect of heparin therapy, which is associated with an increased thrombotic risk [1]. This syndrome is mediated by platelet-activating antibodies, generally targeting platelet factor 4-heparin (PF4-Hep) complexes, and is characterised by an abrupt onset of thrombocytopenia, and, at the same time, by an abnormal thrombin generation resulting in a hypercoagulable state. A thrombotic complication occurs in over half of the patients affected [1]. The diagnosis of HIT is based both on clinical criteria and laboratory assays, but it is often a difficult diagnosis to make and is frequently delayed [2]. This is a case report of one patient with HIT who developed pulmonary embolism and deep vein thrombosis during haemodialysis. A 83-year-old woman with chronic renal failure started haemodialysis because of worsening of renal function (creatinine = 6.5 mg/dl). During each of the dialysis sessions, lasting 3 h, the patient received unfractionated heparin (UFH), with a bolus of 2,000 U followed by 600 U/h by continuous infusion. To facilitate the dialysis procedures, a venous catheter was inserted in the right common femoral vein. After five sessions of dialysis, 12 days after the first administration of UFH, the patient suddenly developed dyspnea, chest and abdominal pain and right leg swelling. Pulmonary embolism, multiple splenic infarctions and deep vein thrombosis of the right leg (from the popliteal to the external iliac vein) were detected by spiral computer tomography and by color-Doppler ultrasonography. The platelet count dropped to 10,000 platelet/mm. Retrospectively, we observed that a decrease in the platelet counts [50% from baseline was already present after the third session of dialysis (from 236,000 to 44,000/mm). An inferior vena cava filter was placed, and anticoagulant therapy with lepirudin (Refludan, Pharmion Ltd) was started at an initial dose of 0.05 mg/kg/h (i.e. 3.5 mg/h) with the aim of maintaining the aPTT ratio between 1.5 and 2.5. The enzyme-linked immunosorbent assay (EIA, GTIHAT, GTI INC, Brookfield WI) to detect PF4/Hep antibodies showed highly positive results (optical density = 2.77; normal value \0.40). Alternative causes of thrombocytopenia, i.e. disseminated intravascular coagulation and thrombotic thrombocytopenic purpura, were excluded. In the following days, the platelet counts remained low (10–15,000/mm); because of severe renal failure, lepirudin monitoring was extremely difficult, with frequent episodes of overanticoagulation (aPTT ratio [ 3.0), despite a reduced dosage (0.0007 mg/kg/h with average of 1.2 mg/ daily); repeated interruptions of lepirudin administration were necessary. The clinical course of the patient was further complicated by sepsis due to methicillin-resistant Staphylococcus aureus: targeted antibiotic treatment was started. Five days after the beginning of lepirudin therapy, the patient started complaining of left leg pain. A colorDoppler ultrasonography showed a new deep vein thrombosis of the left limb, from the popliteal to the common femoral vein. Therefore, lepirudin was replaced with argatroban (Novastan, Mitsubishi Pharma Europe Ltd). The starting argatroban dose was 2 lg/kg/min (corresponding to 7 ml/h) in order to maintain the aPTT ratio between 1.5 and 3.0. A very quick improvement of the clinical picture A. Alatri (&) O. Paoletti A. Zimmermann S. Testa Haemostasis and Thrombosis Centre, A.O. Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100 Cremona, Italy e-mail: a.alatri@ospedale.cremona.it

Laparoscopic distal pancreatectomy and splenectomy for splenic artery aneurysm

Large splenic artery aneurysms are rare but comprise 60% of all visceral artery aneurysms. Most are found incidentally and rupture in the nonpregnant patient has an approximate 25 to 36% mortality rate. Historically these have been managed with an open surgical approach for resection. We present the case of a 43-year-old man with a recent episode of bacterial endocarditis with an incidental finding of a large 6-cm splenic artery aneurysm. There was noted to be splenic vein occlusion and multiple splenic infarcts versus abscesses on preoperative imaging. There were concerns that this represented a mycotic aneurysm. He underwent laparoscopic en bloc splenic artery aneurysm resection with splenectomy and distal pancreatectomy with preoperative prophylactic balloon catheter placement. His large splenic artery aneurysm was adjacent to the splenic hilum. Due to the splenic vein occlusion, there were large collateral vessels complicating the dissection. Additionally, the aneurysm had dense adhesions to the tail of the pancreas from a desmoplastic reaction. To safely remove the aneurysm, a distal pancreatectomy was included with resection of the spleen. The specimen was successfully removed intact using the laparoscopic approach. The patient had an uneventful recovery and was discharged home on postoperative day 2. Final pathology revealed no evidence of bacterial etiology. Laparoscopic distal pancreatectomy with splenectomy is an appropriate minimally invasive option for the treatment of splenic artery aneurysms. This video demonstrates the technical challenges and management options for successfully completing a distal pancreatectomy and splenectomy in the face of a splenic artery aneurysm.

Mimics of Vasculitis: Vascular Ehlers-Danlos Syndrome Masquerading as Polyarteritis Nodosa

To the Editor: A 29-year-old African American man presented to the emergency department following a witnessed generalized seizure, his first. He provided a history of 3 days of abdominal discomfort prior to presentation, associated with constipation. History was remarkable for alprazolam abuse that he recently discontinued, and inguinal hernia repair as a child. There was no significant family history. Physical examination, laboratory studies, and computed tomography (CT) scan of the head were normal. A lumbar puncture was not performed. A second witnessed seizure prompted admission. Over the next 2 days he had no further neurological events but complained of persistent abdominal discomfort. On the third hospital day he developed a fever of 38.5°C associated with leukocytosis and decreasing hemoglobin, but normal chemistry results, amylase, and lipase. CT scan of the abdomen/pelvis revealed a ruptured splenic artery aneurysm with intraabdominal hemorrhage, splenic vein thrombosis, celiac artery aneurysm, bilateral external iliac artery aneurysms, renal artery aneurysm, and multiple splenic and renal infarcts. CT angiography further delineated the extent of the vascular abnormalities (Figure 1). Figure 1. Sequence of reconstructed CT … Address correspondence to Dr. R.A. Badawi, Department of Cardiology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121. E-mail: rbadawi{at}msn.com

Splenic Infarction in Human Babesiosis: Two Cases and Discussion

We describe 2 patients with Babesia infection who presented with fever and multiple splenic infarcts. There were no other conditions present that could potentially be causes of splenic infarction. Although retinal infarction has been described rarely in patients with babesiosis, splenic infarction has not been reported previously in association with this infection in humans.

Splenic Infarction in a Patient with Spent-Phase Polycythemia Rubra Vera (PRV) Treated with Lenalidomide.

Introduction: Lenalidomide (LD) is an oral thalidomide analog with both immunomodulatory and anti-angiogenic properties. It is approved for use in myelodysplastic syndromes (MDS), specifically low-risk and intermediate 1 with 5Q-. LD has also been approved for relapsed multiple myeloma (MM). A major complication associated with LD includes venous thromboembolism (VTE), especially in combination with steroid and erythropoetin (EPO). VTE occurs in 2% of MDS, but range from 6.6% as monotherapy in MM to 8.5%–13.5% when combined with dexamethasone. Zonder reports a preliminary incidence of 75% (9/12 patients) in the SWOG 0302 trial of LD and dexamethasone in previously untreated myeloma. With the addition of ASA in these patients the incidence dropped to 19%. Patients with polycythemia rubra vera (PRV) have a higher incidence of VTE (5.1%> age 70). JAK-2 mutation (tyrosine kinase mutation) occurs as a sporadic event in 75% of patients with PRV and is associated with an older age group, inferior survival, myelofibrosis, acute leukemia and thromboembolic events. Recent studies with LD in this group of PRV and spent-phase myelofibrosis have shown encouraging results. LD has an activity of 46% in myelofibosis by decreasing transfusions and splenomegaly. It would seem to have activity in spent-phase PRV. We report a seminal event of splenic infarction in a patient with PRV and myelofibrosis treated with LD.Case Presentation: A 73 y/o male was diagnosed with PRV 16 yrs earlier. He underwent phlebotomy and received ASA. With a hyperproliferative phase he received hydrea as he was intolerant of IFN-A and anagrelide. Three months earlier, he developed fever, sweats, splenomegaly, and became transfusion dependent. His marrow confirmed myelofibrosis with dysplastic features. LD was begun at 25 mg daily. Three weeks later he developed pneumonia with bronchospasm and required hospitalization for antibiotics and steroids. He improved but returned 4 days later with left upper quadrant pain with CT findings consistent with multiple splenic infarcts. Prednisone was stopped and enoxaparin resulted in marked improvement. Currently, he has marked diminution in the size of his spleen from 13 cm to 4 cm. Currently, he is transfusion independent with marked clinical improvement.Discussion: This report points several dynamic issues within the field of myeloproliferative syndromes. The JAK-2 mutation offers fertile areas of research within MPD disorders as a causative or sporadic mutation and as an associated with several adverse events including VTE and myelofibrosis. We report here a unique occurrence of VTE in the form of multiple splenic infarctions within the context of treatment of the spent-phase of PVR with JAK-2 mutation receiving LD. VTE events associated with LD are associated with DVT or pulmonary embolus and have not been associated with splenic infarction. Splenic infarction has also been reported in myelofibrosis. As further studies confirm efficacy with myelofibrosis it should be suggested that prophylaxis with warfarin or enoxaparin, especially in JAK-2 mutation patients, be considered. Physicians should be encouraged to report their experience in patients with MPD and lenalidomide.