Splenic Infarction: Symptoms, Types, Causes and Treatment

Splenic infarction is a rare but clinically significant condition involving the loss of blood supply to part or all of the spleen, resulting in tissue death. It can be an incidental finding or present with subtle to severe symptoms. Because splenic infarction often signals an underlying disease, recognizing its presentation, understanding its varieties, uncovering the causes, and applying the right treatment are crucial for patient care. This article provides a comprehensive, evidence-based overview of splenic infarction, guided by contemporary research and clinical experience.

Symptoms of Splenic Infarction

Splenic infarction can be a diagnostic challenge due to its variable and sometimes nonspecific symptoms. Some patients may be completely asymptomatic, while others experience acute, severe pain and systemic signs of illness. Recognizing these symptoms is the first step toward timely diagnosis and management.

Symptom	Frequency/Context	Distinguishing Features	Source(s)
Abdominal Pain	Most common, ~66-80%	Usually left upper quadrant	1 2 3 4 5 6 7
Fever	16-70% (varies with cause)	More common in embolic/acute	1 3 4 5 6
Tenderness	~35-36% of cases	Left upper quadrant	2 3 6
Constitutional	Fatigue, malaise, chills	Variable	1 5
Asymptomatic	18-31% in some series	Often in hematologic disease	1 3

Table 1: Key Symptoms

Clinical Presentation

Splenic infarction's presentation is often subtle and easily missed, especially in patients with underlying conditions. The most consistent and characteristic symptom is pain in the left upper quadrant (LUQ) of the abdomen, sometimes radiating to the left shoulder or flank. This pain can be sudden or gradual in onset and may be severe or mild. In some cases, the pain is vague or diffuse, making diagnosis more difficult 1 2 3 4 5 6 7.

Systemic and Local Signs

Fever is another common symptom, particularly when the infarction is due to embolic causes or is complicated by infection. Fever may occur in 16% to 70% of cases, depending on the underlying etiology 1 3 5 6. Left upper quadrant tenderness is found on physical examination in about one-third of cases 2 3 6. Occasionally, patients may show signs of systemic inflammation, including chills, fatigue, and malaise 1 5.

Laboratory and Incidental Findings

Laboratory abnormalities such as leukocytosis (elevated white blood cell count) and elevated lactate dehydrogenase (LDH) can support the diagnosis but are nonspecific 3 4 7. In about 18% to 31% of cases, especially in those with nonmalignant hematologic disorders, splenic infarction may be asymptomatic and detected incidentally during imaging for other reasons 1 3.

Atypical and Pediatric Presentation

In children, splenic infarction may manifest as an abdominal mass or with symptoms of splenic torsion, like severe pain and vomiting. Preoperative thrombocytosis (high platelet count) may help predict infarction in pediatric splenic torsion 13.

Types of Splenic Infarction

Not all splenic infarctions are the same. Understanding the types helps guide diagnosis, management, and prognosis. Infarctions may differ in their extent, underlying pathology, and clinical course.

Type	Description	Clinical Implication	Source(s)
Single Infarct	Isolated area of tissue death	May cause fever, leukocytosis	3 7
Multiple Infarcts	Several discrete areas affected	Often more severe; complications	3 7
Total Infarction	Entire spleen involved	Higher risk of complications	13
Partial Infarction	Segmental, not whole organ	May allow for splenic salvage	13 7

Table 2: Types of Splenic Infarction

Single vs. Multiple Infarcts

• Single Infarcts: These involve a solitary area of necrosis. They are more likely to be associated with fever and leukocytosis, suggesting a stronger inflammatory response 3.
• Multiple Infarcts: These involve several areas within the spleen and are often seen in systemic embolic or thrombotic conditions. Multiple infarcts may be associated with a higher risk of complications such as abscess or rupture 3 7.

Total vs. Partial Infarction

• Total Infarction: The entire spleen is affected, which is rare and typically results from complete occlusion of the splenic artery, such as in torsion (especially in children with wandering spleen) 13. This type is more likely to require surgical intervention.
• Partial Infarction: Only a segment of the spleen is involved, which may allow for conservative, spleen-preserving management 13 7.

Acute vs. Chronic

• Acute Infarction: Sudden loss of blood supply, presenting with abrupt symptoms.
• Chronic or Silent Infarction: May occur in patients with slowly progressive vascular compromise (as in sickle cell disease), sometimes going undetected until incidental imaging or autopsy 1 3 7.

Causes of Splenic Infarction

Identifying the underlying cause of splenic infarction is vital, as it often reveals a serious systemic condition. The spectrum of causes is broad, ranging from hematologic disorders to cardiac emboli, infections, and local vascular events.

Cause/Category	Examples/Associations	Patient Population/Context	Source(s)
Hematologic	Sickle cell, lymphoma, leukemia	Younger patients, chronic disease	1 3 7 14
Thromboembolic	Atrial fibrillation, endocarditis	Older adults, cardiac risk factors	1 4 6 10
Infectious	Endocarditis, malaria, EBV, CMV	Global, immunocompromised hosts	8 9 14
Malignancy	Pancreatic, hematologic, others	Up to 33% of nontraumatic cases	10
Pancreatic Disease	Acute or chronic pancreatitis	Direct vessel invasion, local	10
Vascular/Anatomic	Splenic torsion, trauma, vasculitis	Children, trauma, vasculopathies	13 7 1
Hypercoagulable State	Antiphospholipid syndrome, DIC	Autoimmune, post-infection	5 8

Table 3: Major Causes of Splenic Infarction

Hematologic Disorders

Hematologic diseases are a leading cause, particularly in younger patients. Sickle cell anemia, lymphomas, and leukemias can produce vascular occlusion directly or via hypercoagulability, resulting in splenic infarction 1 3 7 14. In sickle cell disease, repeated microvascular occlusion can lead to chronic, silent infarction and eventual autosplenectomy.

Thromboembolic and Cardiac Conditions

Systemic thromboembolism is a prominent cause, especially in older adults. Cardiac arrhythmias (notably atrial fibrillation), left ventricular thrombi (post-myocardial infarction), and infective endocarditis can all send emboli to the splenic artery 1 4 6 10. Atrial fibrillation is now recognized as the most common predisposing factor in recent cohort studies 4.

Infectious Causes

Splenic infarction can be triggered by infections, either through direct involvement (e.g., infective endocarditis, malaria, Epstein-Barr virus, cytomegalovirus) or by provoking a hypercoagulable state (e.g., transient antiphospholipid antibodies during acute viral infections) 8 9 14. Parasitic diseases like malaria, as well as bacterial and viral infections, are notable contributors, especially in endemic areas or immunosuppressed patients 9.

Malignancies and Pancreatic Disease

Active malignancy, particularly pancreatic cancer, is a significant factor in up to a third of nontraumatic splenic infarctions. Tumors may directly invade splenic vessels or promote a hypercoagulable state. Severe acute pancreatitis can also cause local vascular compromise leading to infarction 10.

Local Vascular and Anatomic Abnormalities

Conditions like splenic artery thrombosis, vasculitis, or splenic torsion (especially in children with wandering spleen) can mechanically disrupt blood flow to the spleen. Splenic torsion presents acutely and often requires surgical intervention 13 1 7.

Hypercoagulable States

Inherited and acquired hypercoagulable states, including antiphospholipid syndrome and disseminated intravascular coagulation (DIC), increase the risk of splenic infarction, particularly in the context of other systemic diseases 5 8.

Treatment of Splenic Infarction

Management of splenic infarction is dictated by the extent of infarction, underlying cause, and presence of complications. Most cases can be managed conservatively, but some require surgical intervention.

Treatment Approach	Indication/Context	Goal/Outcome	Source(s)
Conservative (Support)	Most uncomplicated cases	Pain relief, monitor for issues	7 14
Treat Underlying Cause	Cardiac, infection, etc.	Prevent recurrence, address risk	1 4 6 10
Anticoagulation	Thromboembolic origin	Prevent further embolism	4 6 10
Surgery (Splenectomy)	Complications (rupture, abscess) or torsion	Remove infarcted tissue	1 7 13
Spleen-Preserving	Partial infarction, viable spleen	Preserve immune function	13 14

Table 4: Treatment Modalities

Conservative Management

Most uncomplicated splenic infarctions are managed with supportive care: hydration, pain control with analgesics, and close monitoring. Symptoms generally resolve in 7–14 days. Conservative treatment is particularly favored when the infarction is partial and the risk of complications is low 7 14. Observation with serial imaging may be warranted to ensure resolution.

Addressing the Underlying Cause

Equally important is identifying and treating the underlying etiology:

• Thromboembolic sources: Initiate or adjust anticoagulation therapy as indicated, especially in atrial fibrillation or known hypercoagulable states 4 6 10.
• Infections: Treat the specific infection (e.g., endocarditis, malaria, EBV) with appropriate antimicrobials 9 14.
• Malignancy: Coordinate care for underlying cancer or hematologic malignancy 10.

Surgical Management

Surgery, typically in the form of splenectomy, is reserved for:

• Persistent symptoms despite conservative therapy
• Complications such as splenic abscess, rupture, or pseudocyst
• Total infarction from splenic torsion (especially in children) 1 7 13

Splenic preservation is preferred whenever possible, especially in children, to reduce the risk of overwhelming post-splenectomy infection (OPSI). Spleen-preserving surgery may be considered in partial infarctions or when viable tissue remains 13 14.

Special Considerations in Pediatrics

In pediatric cases of splenic torsion, emergent splenectomy may be necessary if the spleen is completely infarcted. However, if imaging or intraoperative assessment shows viable tissue, spleen-preserving techniques should be prioritized 13.

Prognosis and Follow-up

Most patients recover without major sequelae if managed appropriately. The prognosis worsens with complications or if the underlying disease is severe. Regular follow-up is essential to monitor for late complications or recurrence 7 14.

Conclusion

Splenic infarction, though uncommon, is a critical diagnostic clue to underlying systemic disease and requires a nuanced approach for optimal care.

Key Points:

• Symptoms are variable: Most patients present with left upper quadrant pain, but fever, tenderness, or even silent infarctions are possible 1 2 3 4 5 6 7.
• Multiple types exist: Infarctions can be single, multiple, total, or partial, each with different implications 3 7 13.
• Diverse causes: Etiologies include hematologic disorders, thromboembolic events (notably atrial fibrillation), infection, malignancy, local vascular anomalies, and hypercoagulable states 1 3 4 6 8 9 10 13 14.
• Treatment is usually conservative: Most uncomplicated cases resolve with supportive care; surgery is reserved for complications or total infarction 7 13 14.
• Underlying disease must be addressed: Identifying and managing the root cause is essential for preventing recurrence and improving outcomes 1 4 6 10.

By maintaining a high index of suspicion and applying a structured diagnostic and therapeutic approach, clinicians can improve the detection, treatment, and prognosis of splenic infarction.