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Splenic Infarction in a COVID-19 Patient without Respiratory Symptoms

High rates of thromboembolic events have been seen in cases of COVID-19. Here, we report a case of 23-year-old previously healthy female presented with left-sided abdominal pain associated with vomiting. The computed tomography scan showed multiple ill-defined wedge-shaped low attenuating areas of the spleen, suggesting splenic infarction. In the absence of other thromboembolic contributing factors, we believe this was a thromboembolic event in splenic circulation in relation to COVID-19 infection. Our case adds to the evidence of an arterial thrombotic event in a noncritical COVID-19 patient, emphasizing the importance of addressing thromboembolism diagnosis and management measures to avoid potentially deadly consequences.


Introduction
The coronavirus disease pandemic is a viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), manifesting as an asymptomatic or mild-symptom to severe pneumonia [1,2]. Multiple studies and reports have linked the disease to a thromboembolic event, probably driven by distinct but as yet uncertain processes [3]. Although pulmonary embolism has been the most common thrombotic complication, there have been recent reports of COVID-19-associated largevessel ischemic events such as stroke, acute upper and lower limb ischemia, as well as infarction of the abdominal viscera, including renal, splenic, and small-bowel infarctions [4].
To the best of our knowledge, cases of splenic infarction associated with SARS-CoV-2 infection are rare in the literature. Here, we are reporting a case of splenic infarction in a 23-year-old COVID-19 patient.

Case Presentation
A 23-year-old previously healthy female came to the emergency department complaining of 1-day history of generalized abdominal pain, radiating to the back. The pain was relieved by sitting and worsened on lying flat. It was associated with 20 episodes of vomiting. Patient denied any respiratory symptoms or change in bowel or urine habits.
On examination, she was alert, oriented, and afebrile. The abdomen was soft, with tenderness on deep palpation on the left side of the abdomen (mainly the flank area). The patient was not in acute distress, her respiratory rate was 19, and oxygen saturation was 100%. The lungs were clear on auscultation. The rest of systemic examination was normal. On admission, the SARS-CoV-2 test was done routinely as per the hospital's protocol and came out positive. Computed tomography of the abdomen with IV contrast was done and showed a mildly enlarged spleen with multiple ill-defined wedge-shaped low attenuating areas, involving the entire left lower half, consistent with splenic infarction (Fig. 1, 2).
Blood tests were done to exclude other causes of coagulopathy. Anti-double-stranded DNA, anticardiolipin, antinuclear antibody, anti-beta-2-glycoprotein, complement C3, complement C4, and extractable nuclear antigen profiles were all normal.
The patient was diagnosed with splenic infarction due to coagulopathy caused by SARS-CoV-2 infection. She was started on rivaroxaban (20 mg). The patient was kept on conservative management, and her condition improved.

Discussion
Patients with COVID-19 pneumonia may be predisposed to thrombotic complications due to excess inflammatory response, endothelial dysfunction, platelet activation, and stasis of blood flow [5]. Rates of thrombotic complications may be as high as 31% in patients with COVID-19. For that reason, current guidance statements recommend the use of standard-dose thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin which reduced the incidence by one-half to two-thirds [6].
However, the adequacy of standard thromboprophylaxis is challenged by emerging studies reporting a high incidence of venous thromboembolism (VTE) among anticoagulated patients. A report from France revealed that compared to the matched historic non-COVID-19 cohort, COVID-19 patients with acute respiratory distress syndrome had a 5-fold risk of pulmonary embolism despite anticoagulation (11.7% vs. 2.1%) [7].
Based on aggregate data from cohort studies, 24% of COVID-19 patients who received thromboprophylaxis developed VTE [8]. Some COVID-19 infection cases has been associated with abnormalities in coagulation parameters (e.g., D-dimer, prothrombin time, partial thromboplastin time, fibrin/fibrinogen degradation products, and platelet counts) that are consistent with infection-induced inflammatory changes as observed in disseminated intravascular coagulopathy [9]. Guidelines suggest monitoring D-dimer, fibrinogen, prothrombin time, and platelet count to determine prognosis and assist management decision in COVID-19 patients requiring hospitalization [10]. Deterioration of coagulation parameters may warrant more aggressive critical care support.
Although the most common pattern of coagulopathy observed in patients hospitalized with COVID-19 is characterized by elevations in fibrinogen and D-dimer levels and mild prolongation of PT/aPTT [11], some previous studies showed that the coagulopathy in patients hospitalized with COVID-19 is characterized by increase in INR too. A prospective cross-sectional study was conducted among 455 COVID-19 patients admitted at the COVID-19 care and treatment center, Ethiopia, from July 1 to October 23, 2020, which showed that prolonged INR was more frequent among severe and critical COVID-19 patients [12].
Although rare in the literature, cases of an acute abdomen in COVID-19 patients associated with vascular infarctions of the abdominal viscera, including renal, splenic, and small bowel, have increased. Some cases of CO-VID-19 patients with respiratory symptoms coming with splenic infarction were reported.
Castro et al. [13] reported a case about splenic infarction presented in a COVID-19 patient without any clinical respiratory manifestations of the disease as the patient   presented in our case. This kind of presentation is rare in the literature.
Splenic infarction occurs when blood flow to the spleen is compromised, causing tissue ischemia and eventual necrosis. It may be the result of arterial or venous occlusion. The most commonly associated etiologies are underlying hematologic disorder, blood borne malignancy, blunt abdominal trauma, hypercoagulable state, or embolic illness [14].
Evaluation of patients who present with abdominal pain requires a broad differential approach. Lab evaluation may help rule in/out other causes of abdominal pain. Leukocytosis and elevated lactate dehydrogenase may be found in splenic infarction. Radiographic testing is required to detect this rare illness. In the hyperacute phase of infarction, abdominal CT scan performed with intravenous contrast is the imaging modality of choice in suspected splenic infarction [15]. Treatment of splenic infarct ranges from supportive care to splenectomy.
Dangerous complications of splenic infarction include pseudocyst formation, splenic rupture, and aneurysm. In some instances, the infarcted splenic tissue may become infected and lead to abscess formation. Infarcted tissue may also undergo a hemorrhagic transformation. These complications warrant emergent surgical consultation [16].In our case, the patient did not develop any of these issues, so she was treated conservatively with no surgical intervention.

Conclusion
The cases of thromboembolism of the abdominal viscera including the spleen as a result of COVID-19 infection are increasing. Hence, it is important to suspect ab-dominal visceral infarction in the COVID-19 patient presenting with acute abdominal pain despite the absence of respiratory symptoms. Imaging to confirm the diagnosis and blood tests to exclude other hematological causes of thromboembolism should be done. A prophylactic dose of low-molecular-weight heparin should be considered to reduce the risk of VTE in those who have COVID-19.

Statement of Ethics
Written informed consent was obtained from the patient for publication of this case report and any accompanied images. Ethical approval is not required according to DHA committee policies.