SPLENIC INFARCTS CAUSED BY PARADOXICAL EM BOLI IN SEVERE PULMONARY-HYPERTENSION

History and clinical findings: A 55-year-old woman developed increasin g shortness of breath and breath-independent pain in the left lower ch est. 20 years previously she had had an episode of pulmonary embolism and 10 years previously a central venous thrombosis in the left eye. N o cause of the increased thrombogeneicity had been found. On admission she had resting dyspnoea but a stable circulation. On auscultation th e breath sounds were diminished over the left base and there was a dia stolic murmur over the pulmonary area with an accentuated second sound . There was also marked tenderness below the left costal margin. Recur rent pulmonary embolism or left-sided pleuropneumonia was suspected. I nvestigation: Arterial blood gases (without additional oxygen) showed severe hypoxaemia (pO(2) 42.3 mm Hg, pCO(2) 27.8 mm Hg, pH 7.455, oxyg en saturation 80.5%). Transthoracic and transoesophageal echocardiogra phy showed normal left ventricular dimensions, right atrial and ventri cular dilatation, and an atrial septal aneurysm with a right to left i nteratrial shunt. Right heart catheterisation demonstrated severe pulm onary hypertension. Sonography, computed tomography and scintigraphy r evealed multiple splenic infarcts. Treatment and course: Heparinisatio n was instituted (partial thromboplastin time 70-90 s) and overlapping oral anticoagulation to a Quick value of 20%. Subsequently the calciu m antagonist felodipine (15 mg daily) was given. The mean pulmonary ar tery pressure was 61 mm Hg before and 57 mm Hg after treatment. Conclu sion: Splenic infarction resulting from paradoxical embolisation is ra re, but should be routinely considered in the presence of thromboembol ic phenomena.