Differential diagnosis for spleenic infarcts
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Differential Diagnosis of Splenic Infarcts
Splenic infarction results from either arterial occlusion (embolic/thrombotic) or venous obstruction. The DDx is best organized by mechanism:
Embolic (most common cause overall)
| Condition | Key Features |
|---|---|
| Infective endocarditis | Septic emboli; often multiple infarcts; fever, new murmur |
| Atrial fibrillation | Cardioembolism; left atrial thrombus |
| Dilated cardiomyopathy | LV thrombus source |
| Prosthetic heart valves | Thrombus or vegetation |
| Left atrial myxoma | Tumor embolism; rare but classic |
| Aortic atherosclerosis | Cholesterol/atheroembolism |
Hematological / Thrombotic
| Condition | Key Features |
|---|---|
| Sickle cell disease | Repeated microvascular occlusion → autosplenectomy; most common cause in younger patients |
| Myeloproliferative neoplasms (PV, ET, MF) | Massive splenomegaly + thrombocytosis; high risk |
| Antiphospholipid syndrome | Hypercoagulable; arterial and venous thrombosis |
| Protein C/S deficiency, Factor V Leiden | Thrombophilia screen warranted |
| Paroxysmal nocturnal hemoglobinuria (PNH) | Unusual-site thrombosis |
| TTP / HUS | Microangiopathic occlusion |
| Polycythemia vera | Hyperviscosity + splenomegaly |
Vascular / Local Causes
| Condition | Key Features |
|---|---|
| Splenic artery aneurysm / thrombosis | May be incidental; risk of rupture |
| Splenic vein thrombosis | Associated with pancreatitis, pancreatic carcinoma, post-surgical |
| Portal hypertension | Venous congestion and stasis |
| Vasculitis (e.g., PAN, SLE) | Inflammatory arterial occlusion |
Infiltrative / Structural (splenomegaly → infarction)
| Condition | Key Features |
|---|---|
| Lymphoma / leukemia | Massive splenic infiltration → infarct |
| Metastatic disease to spleen | Rare; may cause segmental infarction |
| Gaucher's disease | Splenic infiltration by glucocerebrosides |
| Amyloidosis | Splenic infiltration |
Iatrogenic / Procedural
- Spleen-preserving distal pancreatectomy
- Splenic artery embolization
- Post-liver/pancreatic transplant vascular complications
Classic Imaging Finding
The characteristic CT appearance is a wedge-shaped hypodensity with its base at the splenic capsule and apex pointing toward the hilum — reflecting the end-arterial vascular anatomy of the spleen.
Contrast-enhanced CT showing a well-defined wedge-shaped area of hypodensity in the splenic parenchyma with a peripheral base, consistent with splenic infarction. This pattern is characteristic of embolic occlusion (e.g., septic embolus from endocarditis).
Clinical Approach
- Young patient + multiple infarcts: think sickle cell, thrombophilia, endocarditis
- Atrial fibrillation: cardioembolism first
- Massive splenomegaly: myeloproliferative disease, lymphoma
- Pancreatitis history: splenic vein thrombosis
- Fever + bacteremia: septic emboli from endocarditis
Workup typically includes echocardiography, hypercoagulable panel, CBC with differential, and blood cultures depending on the clinical context. (Bailey and Love's Surgery, 28th ed., p. 1244)
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