Dear Editor:

We report three cases of splenic infarction during bacterial endocarditis. The first case had an infective endocarditis was due to methicilline sensitive,coagulase negative staphylococcus aureus.He had three rare complications -leaflet perforation and bulging and septic embolic splenic infarction- at the same time(Figures 1 and 2).

Figure 1

Figure 1: Splenic infarct view in his abdominal ultrasonographic imaging.

Figure 2

Figure 2: Splenic infarct area view due to septic embolization in his upper abdominal CT.

Our second case was 58 years old man and serological brucella tests were positive. Thoracoabdominal tomography of our second case showed a triangular hypodense region covering medial splenic region and we thought that it was secondary to splenic infarctus.

Our last case was 60 years old man and treated for MSCONS prediagnosis.He had splenic infarctus which was thought to be secondary to endocarditis.He had also a 1.5x1.5cm perforation defect at mitral anterior leaflet A2 region and a 2x2cm bulging lesion which was thinned and tended to rupture and prolapsed to left atrium.

Comments

Splenic involvement is a classical complication of infective endocarditis(IE). Three types of lesions which may or may not be associated were observed: congestive inflammatory lesions, infarction and abscess(₁).

The significance of septic emboli to the spleen is inferred by the frequency of septic emboli in general seen in patients with left-sided infective endocarditis who are referred for valve replacement(₂). Signs and symptoms are usually poor or aspecific(₃). Splenic infarction usually results in scarring but may progress to abscess formation(₁).

Embolism due to vegetations or infected tissues is the most frequent complication that is closely related with prognosis. The incidence of splenic involvement during endocarditis is approximately 35%(₃).Post mortem studies showed that splenic embolization rate is up to 44 %(₄).

In the study of Haft et al., abdominal computed tomographic scans were performed in 25 consecutive patients with bacterial endocarditis. Six patients had splenic infarcts, only two of whom had symptoms(₅).

In the study of Ting et al.,they reviewed the records of 108 patients with left-sided endocarditis who underwent valvular surgery at the University of Illinois Hospital. The incidence of splenic infarcts and abscess was 19% , but an incidental finding of splenic infarcts was found in 38% of 29 asymptomatic patients who had computed tomograms. Streptococci and staphylococci were the causative organisms in 85% . Abdominal computed tomograms were diagnostic of the sequelae of splenic septic emboli in 100%. No patient had intra-abdominal bleeding complications associated with cardiopulmonary bypass(₂).

Ultrasonography and abdominal CT scanning are the most sensitive diagnostic methods for splenic lesions(₆).But CT scan is probably superior to echography for spleen screening(₃).

Persistant pyrexia and the appearance of local signs should lead to investigation of splenic complications and eventually, to surgical ablation(₁). incidence of abscess requiring specific surgery is very low, inferior to 2%(₃).

Correspondence to

Doç. Dr. Ufuk YETKIN, 1379 Sok. No: 9,Burç Apt. D: 13 - 35220, Alsancak – IZMIR / TURKEY Tel: +90 505 3124906 , Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr