Splenic Infarct: a rare presentation of a common pediatric illness Stephanie Gehle MD, Katherine Schroeder MD, and Steven Weinberg MD Department of Pediatrics, University of North Carolina, Chapel Hill, NC

Introduction Figure 2. Discussion Peripheral smear ❖ Fever, new systolic murmur and recent dental ❖ Splenic infarct is a rare manifestation of underlying without RBC procedure were concerning for infective disease, particularly in pediatric patients and morphologic endocarditis, but no vegetations were seen on patients without risk factors. abnormalities TEE. She continued to fever despite 48 hours of IV or atypical antibiotics. Other infectious etiologies were ❖ Splenic infarcts are most commonly associated with leukocytes. cardioembolic, vascular, or hematologic disorders.1 considered, though CMV PCR and EBV IgM were negative. Differential Diagnosis: ❖ Normal smear, acuity of symptoms, and lack of Acute viral or parasitic infection Presentation lymphadenopathy suggested against malignancy. Infective endocarditis History of Present Illness: Acute leukemia ❖ Though splenic infarct has been reported in autoimmune disorders, this typically is in the Previously healthy 18 year old female presented for Myelodysplastic syndrome acute onset LUQ pain after 4 days of fever, chills, context of antiphospholipid antibodies, which were and NBNB emesis. Hemoglobinopathy negative. Lab findings and lack of chronicity also Figure 1. Initial imaging: Abdominal CT at presenting helped rule out autoimmune process. Review of systems revealed headache, malaise, Hemophagocytic Lymphohistiocystosis ED showed multiple low attenuation foci concerning for muscle aches, and sore throat. No history of trauma Autoimmune disorder splenic infarcts. ❖ Splenic infarct is possible with protein C and S or coagulopathy. No known COVID exposure. deficiency, but our patient's levels were normal.

Diagnostic Evaluation ❖ Quantitative EBV PCR resulted positive after Past Medical, Social, and Family History: discharge, explaining her presentation. Cytopenias History of anxiety and depression on Lexapro. 12.7 COVID/RSV/Flu negative and evidence of extravascular hemolysis were 137 107 6 Ca 8.9 attributed to hypersplenism from acute infection. Recent non-invasive dental procedure. 3.4 108 112 Mg 1.9 14.6 26.5 EBV IgG and IgM negative Sexually active with Nexplanon. No condom use. 3.7 23 0.73 Phos 3.2 CMV PCR negative 36.7 ❖ While there are case reports of splenic infarct in Denies drug use. 1.24 EBV quantitative PCR 15,279 the setting of infectious mononucleosis with EBV, No family history of clotting or bleeding disorders. ANC 1.9 Uric acid 2.7 Hemoglobin electrophoresis normal this is rare and thus may be easily Reticulocytes 1.5% LDH 1,013 0.7 67 96 6.1 Protein C, S, and ATIII activity normal overlooked.2,3 Pathogenesis of splenic infarcts in Triglycerides 227 Haptoglobin <20 these cases is unknown. Initial Assessment: Ferritin 569 Fibrinogen 275 0.3 66 3.3 Beta-2 glycoprotein and cardiolipin antibodies normal T 39.3 °C (Oral) | BP 121/80 | HR 110 | Resp 18 | CRP 63 D-dimer 888 SpO2 96% Factor II/V mutation testing negative References Blood cultures: No growth for 5 days Flow cytometry for PNH negative Exam: Uncomfortable febrile teen. Tachycardic with 1. Wand O, Tayer-Shifman OE, Khoury S, Hershko AY. A practical approach to infarction of 3/6 systolic murmur. TTP in LUQ. No HSM, edema, Peripheral blood smear unremarkable (Figure 2) the spleen as a rare manifestation of multiple common diseases. Ann Med. 2018 ANA negative Sep;50(6):494-500. rashes, or LAD. EKG with normal sinus rhythm HIV negative 2. Heo DH, Baek DY, Oh SM, Hwang JH, Lee CS, Hwang JH. Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection. J TTE/TEE: Normal function, no vegetations present Rheumatoid factor normal Med Virol. 2017 Feb;89(2):332-336. 3. Jeong JE, Kim KM, Jung HL, Shim JW, Kim DS, Shim JY, Park MS, Park SK. Acute Patient was accepted for transfer to UNC Peds ED Liver and spleen ultrasound: Normal blood flow, splenomegaly Urine pregnancy negative Gastritis and Splenic Infarction Caused by Epstein-Barr Virus. Pediatr Gastroenterol based on initial imaging findings shown in Figure 1. Hepatol Nutr. 2018 Apr;21(2):147-153. doi: 10.5223/pghn.2018.21.2.147. Epub 2018 Bilateral lower extremity PVLs: No DVT CT abdomen/pelvis (see Figure 1) Apr 13. PMID: 29713613; PMCID: PMC5915693.