Clinicopathologic Features of COVID-19: A Case Report and Value of Forensic Autopsy in Studying SARS-CoV-2 Infection.

ABSTRACT: As of August 23, 2020, the 2019 novel coronavirus disease (COVID-19) has infected more than 23,518,340 people and caused more than 810,492 deaths worldwide including 4,717 deaths in China. We present a case of a 53-year-old woman who was admitted to the hospital because of dry coughs and high fever on January 26, 2020, in Wuhan, China. She was not tested for SARS-CoV-2 RNA until on hospital day 11 (illness day 21) because of a significant shortage of test kits at the local hospital. Then, her test was positive for COVID-19 on hospital day 20. Despite intensive medical treatments, she developed respiratory failure with secondary bacterial infection and expired on hospital day 23 (3 days after she was tested positive for SARS-CoV-2 RNA). A systemic autopsy examination, including immunohistochemistry and ultrastructural studies, demonstrates that SARS-CoV-2 can infect multiple organs with profound adverse effect on the immune system, and the lung pathology is characterized by diffuse alveolar damage. Extrapulmonary SARS-CoV-2 RNA was detected in several organs postmortem. The detailed pathological features are described. In addition, this report highlights the value of forensic autopsy in studying SARS-CoV-2 infection and the importance of clinicopathological correlation in better understanding the pathogenesis of COVID-19.

Multiple Splenic Infarcts Complicating Plasmodium vivax Malaria.

Splenic infarct is a rare complication in Plasmodium vivax malaria. We report a case of splenic infarction with acute kidney injury in a case of P. vivax malaria in a 13-year-old male child who presented to the emergency department with severe pain in the left hypochondrium. The patient was managed with intravenous artesunate and oral primaquine. Pain in left hypochondrium in children with P. vivax malaria due to splenic infarction needs to be evaluated for any surgical emergency like rupture or abscess. A review of literature of the unusual but serious complication is presented along with the case report.

A Case of Autosplenectomy in Sickle Cell Trait Following an Exposure to High Altitude.

A 24-year-old man presented with acute abdominal pain upon ascent to moderate altitude (3500 m). An immediate evaluation revealed a splenic infarct, and he was evacuated to sea level. Upon recovery, he was sent back to 3500 m without detailed etiological evaluation, whereupon he experienced recurrent episodes of left-side subcostal pain. Imaging suggested autosplenectomy, and workup revealed a negative thrombophilia profile but was positive for sickle cell trait (SCT). Individuals with SCT can be asymptomatic until exposure to severe hypoxia, upon which they can manifest clinically as sickle cell syndrome. We discuss the rare presentation of autosplenectomy in a patient with previously undiagnosed SCT on exposure to high altitude.

Two Imported Cases of Babesiosis with Complication or Co-Infection with Lyme Disease in Republic of Korea.

Babesiosis, caused by Babesia microti and B. divergens, is transmitted by Ixodid ticks. Symptoms of babesiosis vary from a mild flu-like illness to acute, severe, and sometimes fatal and fulminant disease. In Korea, 7 imported babesiosis cases and 1 endemic case have been reported. We report 2 cases of severe babesiosis initially mistaken as malaria. The first patient was complicated by shock and splenic infarction, the other co-infected with Lyme disease. As the population traveling abroad increases every year, physicians should be aware of babesiosis which mimics malaria, co-infection with other diseases, and its complications.

Splenic infarction associated with acute infectious mononucleosis due to Epstein-Barr virus infection.

The purpose of this study was to report a case of a previously healthy 20-year-old woman diagnosed with splenic infarction following infectious mononucleosis (IM) by Epstein-Barr virus (EBV) infection and to perform the first systematic review of the clinical characteristics of splenic infarction associated with IM. A systematic review was conducted using English, French, and Japanese literatures of splenic infarction associated with IM due to EBV infection published between 1961 and 2015 in PubMed Medline. A total of 19 cases were extracted from the collected articles. Left upper quadrant (LUQ) pain was observed in 15 (79%) patients. Splenectomy was performed in five (26%) cases, among which four patients presented with stable vital signs. Splenic rupture was accompanied in two (10%) patients. The median time from the onset of IM symptoms to the diagnosis of splenic infarction was 5 days (range, 1-25 days). Fourteen (74%) of 19 patients experienced improvement through medical treatment, and there were no deaths. Splenic infarction associated with IM due to EBV infection can show a favorable clinical outcome after medical treatment. Clinicians should consider the possibility of splenic infarction when patients with IM experience LUQ pain. J. Med. Virol. 89:332-336, 2017. © 2016 Wiley Periodicals, Inc.

[The infarction or the traumatic rupture of the spleen?] / Infarkt ili travmaticheskii razryv selezenki?

The clinical observation reported in the present article is of special interest for the forensic medical experts taking into consideration the rare occurrence of infarction of the spleen in the medical legal practice. More comprehensive detailed information about such cases is needed for their thorough in-depth investigation and systematization of the differential diagnostic signs and clinical manifestations of the injury (rupture of the spleen) and pathology of the organ (infarction) for the purpose of the more reliable differentiation between these conditions, creation of the relevant diagnostic database, formulation of more conclusive recommendations, and their better substantiation.

Partial splenic embolization for thrombocytopenia in liver cirrhosis: predictive factors for platelet increment and risk factors for major complications.

OBJECTIVES: To investigate the predictors of platelet increment and risk factors for major complications after partial splenic embolization (PSE) in cirrhosis. METHODS: Between March 2010 and June 2012, 52 cirrhotic patients with severe thrombocytopenia underwent PSE. Multiple variables were analyzed to identify the correlated factors affecting platelet increment and major complications after PSE. RESULTS: Linear mixed model analysis indicated the splenic infarction ratio (P < 0.001), non-infarcted splenic volume (P = 0.012), and cholinesterase level (P < 0.001) were significantly associated with the platelet increment after PSE. In receiver operating characteristic (ROC) analysis, the cut-off values of the splenic infarction ratio, and non-infarcted splenic volume for achieving an increment of ≥60.0 × 10(9)/L in platelet counts at 1 year after PSE were 64.3% and 245.8 mL, respectively. After PSE, eight patients developed major complications. Multivariate logistic regression analysis indicated major complications were significantly associated with the infarcted splenic volume (P = 0.024) and Child-Pugh score (P = 0.018). In ROC analysis, the cut-off values of these two factors for discriminating the uncomplicated and complicated were 513.1 mL and 9.5, respectively. CONCLUSIONS: The platelet increment after PSE depends on the splenic infarction ratio, non-infarcted splenic volume and cholinesterase level. But a large infarcted splenic volume and a high Child-Pugh score may cause complications. KEY POINTS: • The platelet increment after PSE greatly depends on the splenic infarction ratio. • The non-infarcted splenic volume significantly affects the efficacy of PSE. • A high cholinesterase level contributes to the improvement of thrombocytopenia after PSE. • The non-infarcted splenic volume significantly affects the relapse of hypersplenism. • Complications are significantly associated with the infarcted splenic volume and Child-Pugh score.

Comparison of volume and attenuation of the spleen between postmortem and antemortem computed tomography.

OBJECTIVES: The purpose of this study is to compare the postmortem changes in computed tomography (CT) findings between normal spleen, splenic infarct, and splenic tumor infiltration. METHODS: The institutional review board approved this study, and informed consent was obtained from the next of kin. We studied 63 consecutive subjects who underwent antemortem CT, postmortem CT, and autopsy between February 2012 and December 2013. Postmortem CT was performed within 1678 min after death and was followed by pathological studies. The subjects were divided into three groups based on the pathological findings: normal, splenic infarct, and splenic tumor infiltration. The volume and attenuation of the spleen were compared between antemortem and postmortem CT using paired t tests. Gender, age, time elapsed since death, and the causes of death were examined as potential confounding factors of the postmortem changes in volume and attenuation. RESULTS: In all groups, the spleen decreased in volume and attenuation increased on postmortem CT compared with antemortem CT. The postmortem changes in spleen volume and attenuation were not significantly associated with sex, age, time elapsed since death, or causes of death. CONCLUSIONS: Spleen volume decreased and attenuation increased on postmortem CT compared with antemortem CT in subjects with a normal spleen, splenic infarct, or splenic tumor infiltration. These results should caution us against underestimating the significance of splenomegaly on postmortem CT, misinterpreting reduced splenic volume as the presence of hypovolemic or distributive shock in the subject while alive, and confusing postmortem splenic hyperattenuation with diseases characterized by this finding.

Splenic Infarction in Acute Infectious Mononucleosis.

BACKGROUND: The evaluation of a febrile patient with acute abdominal pain represents a frequent yet possibly challenging situation in the emergency department (ED). Splenic infarction is an uncommon complication of infectious mononucleosis, and may have a wide range of clinical presentations, from dramatic to more subtle. Its pathogenesis is still incompletely understood, yet it may be associated with the occurrence of transient prothrombotic factors. CASE REPORT: We report the case of a 14-year-old boy who presented with fever, sore throat, left upper quadrant abdominal pain, and splenomegaly, with no history of recent trauma. Laboratory tests revealed a markedly prolonged activated partial thromboplastin time and positive lupus anticoagulant. Abdominal ultrasonography showed several hypoechoic areas in the spleen consistent with multiple infarctions. Magnetic resonance imaging eventually confirmed the diagnosis. He was admitted for observation and supportive treatment, and was discharged in good condition after 7 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous splenic infarction should be considered in the differential list of patients presenting with left upper quadrant abdominal pain and features of infectious mononucleosis; the diagnosis, however, may not be straightforward, as clinical presentation may also be subtle, and abdominal ultrasonography, which is often used as a first-line imaging modality in pediatric EDs, has low sensitivity in this scenario and may easily miss it. Furthermore, although treatment is mainly supportive, close observation for possible complications is necessary.

Splenic infarction as a rare complication of infectious mononucleosis due to Epstein-Barr virus infection in a patient with no significant comorbidity: case report and review of the literature.

We report the case of a 17-y-old boy diagnosed with infectious mononucleosis due to Epstein-Barr virus infection who complained of left upper quadrant pain. A magnetic resonance imaging scan showed a splenic infarct in the enlarged spleen. Other causes of splenic infarction were excluded. Thus, infectious mononucleosis may cause splenic infarction in patients without other comorbidities.

Case report: cytomegalovirus-induced thrombosis in an immunocompetent patient.

Thrombotic manifestations of cytomegalovirus infection in immunocompetent individuals are rare. However, it has been postulated that cytomegalovirus infection can be both directly cytopathic and capable of inducing antiphospholipid antibodies due to shared "molecular mimicry" between cytomegalovirus virus antigens and antiphospholipid antibodies. The case of a previously well 30-year-old woman with primary cytomegalovirus infection complicated by splenic infarction and massive pulmonary embolus is described. The patient is unusual given the development of thromboses affecting both the arterial and venous circulation, associated with both transient anticardiolipin antibodies and persistently positive anti-ß(2) glycoprotein I antibodies. The temporal relationship between the primary infection and thrombosis was suggestive of a pathogenic role for cytomegalovirus.

A case of splenic infarction possibly attributable to Mycoplasma pneumoniae infection without accompanying pneumonia.

We report a case of a patient with splenic infarction possibly attributable to Mycoplasma pneumoniae infection without accompanying pneumonia. A 24-year-old man was admitted to our hospital with a 7-day history of fever, sore throat, and left upper-quadrant abdominal pain. Chest radiography revealed no active lung lesions; however, abdominal computed tomography showed hepatosplenomegaly with splenic infarction. At the time of admission, the patient's serum IgM titer for M. pneumoniae was 79.7 U/mL (positive titer >70 U/mL). Two weeks later, the serum IgM titer for M. pneumoniae had markedly increased to 3,158.1 U/mL. The patient was treated with azithromycin, and his symptoms began to improve. After 5 weeks, the spleen size decreased, and a scar was observed at the site of the infarct.

A case of functional asplenia and pneumococcal sepsis.

Asplenia may refer to the spleen's surgical removal, functional impairment, or congenital absence. It is a risk factor for the development of severe bacterial infection. Functional asplenia is likely the most common presentation of this entity and has many etiologies. Those that are previously undiagnosed may present completely well until an episode of overt sepsis develops. The true incidence of mortality secondary to functional asplenia remains elusive. As lifetime mortality remains exceedingly high in the asplenic population regardless of etiology, markers of hyposplenism are important to detect. The present report describes an infant with trisomy 21 and previously undiagnosed functional asplenia who ultimately experienced overwhelming pneumococcal sepsis with features of Waterhouse-Friderichsen syndrome and died within 12 hours of initial presentation. It is a poignant reminder of what features to be cognizant of on peripheral blood smear in a previously well child, who may be at risk for a devastating consequence.

Risk assessment and prognostic analysis of patients with splenic infarction in emergency department: a multicenter retrospective study.

Splenic infarction is a thromboembolic disease that is frequently missed in acute settings. Previous reviews were rarely presented from a clinical perspective. We aimed to evaluate the clinical characteristics, risk factors with diagnostic value, and prognostic factors using large cohort data and a matched case-control study method. A retrospective medical record review of six hospitals in Taiwan from January 1, 2005, to August 31, 2020, was conducted. All patients who underwent contrast CT with confirmed the diagnosis of splenic infarction were included. Their characteristics were presented and compared to a matched control group with similar presenting characteristics. Prognostic factors were also analyzed. A total of 130 cases were included, two-thirds of whom presented with abdominal pain. Atrial fibrillation was the most common associated predisposing condition, followed by hematologic disease. A higher proportion of tachycardia, positive qSOFA score, history of hypertension or atrial fibrillation, leukocytosis, and thrombocytopenia were found in splenic infarction patients compared to their counterparts. An underlying etiology of infective endocarditis was associated with a higher proportion of ICU admission. Splenic infarction patients often presented with left upper abdominal pain and tachycardia. A history of hypertension, atrial fibrillation, a laboratory result of leukocytosis or thrombocytopenia may provide a clue for clinicians to include splenic infarction in the differential list. Among the patients diagnosed with splenic infarction, those with an underlying etiology of infectious endocarditis may be prone to deterioration or ICU admission.

Clostridium tertium Peritonitis and Bacteremia in a Neonate With Congenital Intestinal Atresia: A Case Report.

We report a 1-day-old girl who was affected by peritonitis and bacteremia caused by Clostridium tertium following perforation of congenital intestinal atresia. Splenic infarction was also suspected during C. tertium bacteremia. C. tertium was identified by using mass spectrometry and 16S rRNA sequencing. This patient was successfully treated with emergency laparotomy and broad-spectrum antibiotics.

Case Report: Splenic Infarction in Infectious Mononucleosis due to Epstein-Barr Virus Infection.

Epstein-Barr virus (EBV) is the most common cause of infectious mononucleosis (IM) and IM is a clinical syndrome typically characterized by fever, pharyngitis, and cervical lymph node enlargement. We describe the case of a 19-year-old man with IM complicated by splenic infarction. The patient visited our hospital because of upper abdominal pain without a fever and sore throat. Abdominal computed tomography revealed a low-density area in the spleen, which indicated splenic infarction. The next day, he developed a fever. After diminishing abdominal pain and fever, he developed pharyngitis accompanied by fever. Acute EBV infection was confirmed by serological tests. The patient was successfully managed with no specific therapy. Splenic infarction is a rare complication of IM and this case showed that splenic infarction can precede a fever and pharyngitis.

Splenic infarction during Plasmodium ovale acute malaria: first case reported.

The splenic complications of acute malaria include two different prognostic and treatment entities: splenic infarction and splenic rupture. This is the first case of splenic infarction during an acute malaria due to Plasmodium ovale in a 34-year-old man. As in the majority other described cases of splenic infarction, the course was spontaneously favourable, suggesting that this complication was relatively benign compared to splenic rupture, which is life-threatening and usually necessitating surgery.

[Splenic gangrene due to Streptococcus anginosus after a sleeve gastrectomy. Report of one case]. / Gangrena esplénica por Streptococcus anginosus post manga gástrica laparoscópica complicada con hemoperitoneo y comunicación gastroesplénica secundaria. Caso clínico.

We report a 46-year-old woman, subjected to a laparoscopic sleeve gastrectomy, that had to be converted to open surgery due to the presence of adherences. She required an immediate new intervention due to a hemoperitoneum caused by a liver tear and venous bleeding from the splenic hilus. Both lesions were successfully repaired. In the postoperative period the patient had fever, leukocytosis and sialorrhea. A CAT scan showed a splenic infarction and a huge intra abdominal collection that communicated with the stomach. Streptococcus anginosus was isolated from the collection. The patient was managed with antimicrobials and percutaneous drainage with a favourable evolution and closure of the communication with the stomach.

Atrial myxoma with cerebellar signs: a case report.

BACKGROUND: Atrial myxoma remains a rare clinical entity with an incidence of surgically resected cases of 0.5-0.7 per million population and prevalence of < 5 per 10,000. It typically manifests in woman after third decade of life; symptoms vary greatly and may present with arrhythmia, intracardiac flow obstruction, embolic phenomenon, and associated constitutional symptoms. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Cerebellar involvement is very rare and only a few cases have been reported in the literature. CASE PRESENTATION: A 55-year-old Brahmin man with no history of diabetes mellitus and hypertension, presented with complaints of dizziness, headache, vomiting, double vision, and unsteadiness of gait for 2 weeks. His headache was sudden in onset, of a pulsating type and localized on left temporal side. Vomiting was projectile and bilious. Double vision was present in all directions of gaze and he had uncoordinated movement of his body and tilting to the left side. On examination, his cerebellar functions were impaired. He was thoroughly investigated for the cause of stroke after abnormal magnetic resonance imaging results with normal computed tomography angiography of his brain. Echocardiography and computed tomography of his chest showed a mass attached to intra-atrial septum and prolapsing through mitral valve, which was suggestive of left atrial myxoma. Five days following admission, he developed abdominal pain due to thromboembolism causing splenic and renal infarct. CONCLUSION: Although rare, atrial myxoma has to be considered a cause of stroke and other embolic phenomenon causing multiorgan infarctions. Early and timely diagnosis of the condition can prevent further recurrence and inappropriate anticoagulant therapy. It would be pertinent to have echocardiography done in patients who present with a stroke, arrhythmias, and other constitutional symptoms. The tumor once detected must be removed surgically as early as possible, which not only reduces serious thromboembolic complications but can be potentially curative.