Guidelines for Diagnosis and Management of Splenic Infarction
Diagnostic Approach
- Contrast‑enhanced CT of the abdomen is the preferred imaging modality, providing 90‑95 % sensitivity and specificity for detecting splenic infarction and splenic abscess. 1, 2, 3, 4
- On CT, bland (non‑infected) infarcts appear as peripheral, wedge‑shaped, low‑density areas. 1, 3
- Abscess formation is suggested by single or multiple contrast‑enhancing cystic lesions on CT. 1
- Ultrasound is less sensitive than CT for initial diagnosis but can be useful for follow‑up monitoring of complications such as liquefaction, subcapsular hemorrhage, or free intraperitoneal fluid. 3
- MRI demonstrates comparable sensitivity and specificity (≈90‑95 %) to CT but is not routinely used as first‑line imaging in the acute setting. 1
- Technetium‑99m liver‑spleen scans, labeled white‑blood‑cell scans, and gallium scans are no longer recommended for evaluating splenic infarction. 1
Etiological Workup
- Splenic infarction occurs in roughly 40 % of patients with left‑sided infective endocarditis (IE); only about 5 % of these progress to splenic abscess. 1, 5
- The most common organisms isolated from IE‑related splenic abscesses are Viridans streptococci (≈40 %), Staphylococcus aureus (≈40 %), and enterococci (≈15 %). 1
Management of Uncomplicated Splenic Infarction
- Conservative medical therapy—adequate hydration, analgesia, and close clinical monitoring—is the standard of care. 1, 2
- Clinical improvement is indicated by:
Indications for Surgical Intervention (Complicated Infarction)
Splenectomy (with appropriate antibiotics) is indicated when any of the following are present:
Surgical options:
Timing Relative to Cardiac Surgery
- When concurrent infective endocarditis requires valve replacement, splenectomy should be performed before valve surgery whenever feasible to reduce the risk of prosthetic valve seeding from ongoing bacteremia. 7, 8
- In cases of urgent valve surgery, splenectomy may be deferred or performed simultaneously, depending on clinical urgency. 2
Differentiating Bland Infarction from Splenic Abscess
Bland infarction:
Splenic abscess:
Clinical Pitfalls
- Splenomegaly is an unreliable sign, present in only ~30 % of IE patients with splenic involvement, and should not be used to rule in or out infarction/abscess. 1, 4