A 68-year-old male was admitted to our hospital due to fever and abdominal pain in the left lower quadrant that started 2 days prior to admission.

His past medical history was significant for coronary artery by-pass surgery 15 years earlier, perforation of the stomach 20 years earlier, and atrial fibrillation. His medication included acenocoumarol, isosorbide mononitrate, ramipril, furosemide, and carvedilol. The patient had dental work done 7 days prior to admission. He reported that he had stopped taking some of his medications, including acenocoumarol, prior to the visit to the dentist. However, two days prior to his admission he re-started taking acenocoumarol.

His temperature was 37.8 degrees Celsius. His blood pressure was 130/80 mmHg and his pulse rate was 120/min. Physical examination showed left lower quadrant abdominal tenderness and decreased bowel sounds. Routine laboratory testing showed: ALP 223 U/L, SGOT 41 U/L, ã-GT 239 U/L, total bilirubin 2.3 mg/dL, INR 2.33, prothrombin time 28.4 sec, partial thromboplastin time 49.2 sec, white blood cell count 15.70 K/ìl, neutrophills 83.5%, red blood cell count 3.77 M/ìl, hematocrit 39.3%, C- reactive protein 26.57 mg/dL (normal values up to 0.5 mg/dL), urea 34 mg/dL, creatinine 1.2 mg/dL.

A CT scan of the abdomen showed an area of hypodensity of the spleen with a size of 9.5x3 cm (Figure). Ascites was also noted.

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