Asplenic patient

Background

Causes of asplenia

• Congenital
• Prior splenectomy for:
  • Previous hypersplenism
  • Sickle cell disease
  • Immune thrombocytopenic purpura
  • Hodgkin's lymphoma
  • Thalassemia
  • Hereditary spherocytosis
  • Splenic rupture/hemorrhage
• Functional
  • Sickle cell disease

Clinical Features

Presentation

• Sickle-cell disease patient over the age of 8
• absent spleen on CT
• otherwise asplenic patient

Asplenia increases risk of (and worsens course of)

• Pneumonia
• Sepsis/septicemia
• Babesiosis, Ehrlichiosis
• Infections from encapsulated bacteria (e.g. Strep Pneumo, H. influenzae, Neiserria Meningitidis)
• Viral illnesses

Signs/symptoms of infection

• cough, fever, rigors, malaise
• nausea/vomiting, constipation/diarrhea
• urinary symptoms
• wound infection
• rash
  • increased oxygen requirement, tachycardia

Differential Diagnosis

• Bacterial infection (sepsis)
  • Streptococcus pneumonia
  • Haemophilus influenzae type B
  • Neisseria meningitidis
  • Capnocytophaga canimorsus
  • Bordetella holmesii
• Viral illness

CT of an asplenic patient

Evaluation

Workup

• CBC (elevated WBC, platelets)
• BMP, lactate
• CXR
• Blood cultures, urine, wound cultures
• Peripheral blood smear
  • Howell Jolly bodies
  • Heinz Bodies
  • Pappenheimer bodies
  • Target cells

Post-splenectomy blood smear demonstrating Howell-Jolly bodies and target cells.

Management

Sepsis

• 30mL/kg fluids
• broad spectrum antibiotics appropriate for suspected infection
• overwhelming majority of cases are from streptococcus

Fever (no sepsis)

• treat empirically with antibiotics
  • amoxicillin-clavulanate: 90mg/kg amox per day in children divided into two doses; 875 mg/125 bid for adults
  • cefuroxime: 30mg/kg per day in children divided into two doses; 500mg bid for adults
  • levofloxacin 750 mg once daily (adults or adolescents only)
  • moxifloxacin 400 mg once daily (adults or adolescents only)
  • gemifloxacin 320 mg once daily (adults or adolescents only)

Vaccination management

• 4 doses of PCV13 before 15 months
• PPSV23 at least 8 weeks after last PCV13, first at age 2
• 2nd dose of PPSV23 3 years after first
  • (if patient is >6years and has not received PCV13 or PPSV23, dose 1 time with PCV13 then dose with PPSV23 8 weeks later)
  • (if patient is >6years but <18 years and has not received PCV13 but has received PPSV23, dose 1 time with PCV13 at least 8 weeks after last PPSV23)
  • (if patient is >18 years and has not received PCV13 but has received PPSV23, dose 1 time with PCV13 at least 1 year after last PPSV23)
• Redose PPSV23 every 5 years
• Hib conjugate vaccine for all unvaccinated patients above the age of 5 years
• inactivated influenza vaccine yearly
• Neisseria meningitidis vaccine for asplenic adults

Prophylaxis

• Daily Penicillin VK or amoxicillin
• for children up to age of 5 or for 1 year following splenectomy
• potentially up to age of 18 for highly immunocompromised individuals

Disposition

• Based on presenting complaint/illness (asplenia by itself is not an indication for admission)
• Consider admitting asplenic patients presenting with fever

See Also

• Vaccination schedule
• Sepsis

References

Authors

Ross Donaldson, Michael Holtz, Claire