Infectious Disease Compendium

Asplenia

Diagnosis

Spleen gone. Usually not a subtle finding on history or CT; Howell-Jolie bodies can be a hint on the smear.

Epidemiologic Risks

Trauma (you do wear your seat belt?), sloppy surgeon, the following incomplete list can act as if they are asplenic: Alcoholism, amyloidosis, autoimmune hemolytic anemia, biliary cirrhosis, bone marrow transplantation, celiac disease, chronic active hepatitis, chronic graft vs. host reaction, chronic myelogenous leukemia, collagenous colitis, essential thrombocythemia, Graves' disease, hairy cell leukemia, Hashimoto's thyroiditis, hemangiosarcoma of the spleen, hemophilia, hematologic diseases, hereditary spherocytosis, Hodgkin's disease, idiopathic thrombocytopenic purpura, non-hodgkin's lymphoma, ovarian carcinoma, portal hypertension, rheumatoid arthritis, right sided heart failure, sarcoidosis, Sjögren's syndrome, splenic irradiation, systemic lupus erythematosus, thalassemia, ulcerative colitis, Whipple's disease.

It is not that they get more infections, but that they get worser infections (Purpura fulminans), especially with encapsulated organisms.

Microbiology

Streptococcus pneumoniae, Haemophilus influenzae, Salmonella, Capnocytophagia canimorsus, Malaria, Babesia, Meningococcus. B. holmseii can cause bacteremia and it peaks with Pertussis cases (PubMed).

Empiric Therapy

Vancomycin and (a third generation cephalosporins OR carbapenem OR penicillin/beta-lactamase inhibitors OR quinolone).

Pearls

There is this neat thing out called the vaccine and it exists for both Streptococcus pneumoniae and Haemophilus influenzae. Perhaps it would be nice to give the vaccine BEFORE you remove that spleen.

Care of the Asplenic Patient (From NEJM Review)

• Asplenic patients are at risk for episodes of rapidly progressive septicemia that are fatal in up to 50% of cases.

• Asplenic patients should be informed that any illness with fever or severe symptoms without fever could indicate the onset of a life­threatening infection.

• Asplenic patients in whom fever develops should receive empirical antimicrobial therapy immediately.

• Vaccinations against pneumococci, Haemophilus influenzae type b, meningococci, and influenza virus are recommended for asplenic patients.

• Prophylactic antimicrobial therapy is generally recommended for asplenic children younger than 5 years of age and may be considered for older children and adults during the initial 1 to 2 years after splenec­tomy, with lifelong prophylaxis for persons who have had an episode of postsplenectomy sepsis.

Rants

I remain amazed at the number of splenectomy patients who have not been warned that they can get sicker than stink faster than a Republican can go to war. Tell your patient about the seriousness of fever and give them the damn vaccine. How often? My bias is the pneumococcal vaccine every five years and I suggest both the old carbohydrate AND the newer conjugated. This is a clinical trial free practice, but when you look at the pharmacokinetics of antibody after vaccine in the asplenic, it seems prudent.