An unusual cause of abdominal pain

A 44-year-old man was referred for acute abdominal pain of the upper left quadrant. His medical history was unremarkable and he was taking no medicine. On exami- nation, the abdomen was soft and tender to palpation at the left costovertebral angle. Cardiac auscultation re- vealed a grade 3/6 pansystolic murmur over the left low- er sternal border. The white-cell count was 12.000 per cubic millimetre, the C-reactive protein was 20 mg/L and the LDH 500 U/L. Liver and pancreatic enzymes were normal. While the patient was in the emergency depart- ment narcotic analgesia was administered intravenously to control pain. Computer tomography of the abdomen showed multiple wedge-shaped areas of hypoenhase- ment in the spleen, consistent with splenic infarcts (Fig. 1).