Asplenic patient: Difference between revisions

(Created page with "==Background== ===Causes of asplenia=== *Congenital *Surgical **Previous hypersplenism **Sickle cell disease **Immune thrombocytopenic purpura **Hodgkin's Lymphoma **Thalassem...")
 
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===Causes of asplenia===
===Causes of asplenia===
*Congenital
*Congenital
*Surgical
*Prior splenectomy for:
**Previous hypersplenism
**Previous hypersplenism
**Sickle cell disease
**[[Sickle cell disease]]
**Immune thrombocytopenic purpura
**[[Immune thrombocytopenic purpura]], [[TTP]], [[autoimmune hemolytic anemia]]
**Hodgkin's Lymphoma
**[[Hodgkin's lymphoma]]
**Thalassemia
**[[Thalassemia]]
**Hereditary spherocytosis
**[[Hereditary spherocytosis]]
**[[Splenic injury]] (rupture/hemorrhage)
*Functional
*Functional
**Sickle cell disease
**[[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)===
===Asplenia increases risk of (and worsens course of)===
*Pneumonia
*[[Pneumonia]]
*Sepsis/septicemia
*[[Sepsis]]/septicemia
*Infections from encapsulated bacteria
*[[Babesiosis]], [[Ehrlichiosis]]
*Viral diseases
*Infections from encapsulated bacteria (e.g. [[Strep pneumo]], [[H. influenzae]], [[Neisseria meningitidis]])
*[[viral syndrome|Viral illnesses]]


===Signs/symptoms of infection===
*[[Cough]], [[fever]], rigors, malaise
*[[Nausea/vomiting]], [[constipation]]/[[diarrhea]]
*[[dysuria|Urinary symptoms]]
*wound infection
*[[Rash]]
*[[Hypoxia|Increased oxygen requirement]], [[tachycardia]]


==Differential Diagnosis==
*[[bacterial disease|Bacterial infection]] ([[sepsis]])
**[[Streptococcus]] pneumonia
**[[Haemophilus influenzae]] type B
**[[Neisseria meningitidis]]
**[[Capnocytophaga canimorsus]]
**[[Bordetella holmesii]]
*[[Viruses|Viral illness]]


==Clinical Features==
[[File:Asplenia.jpg|thumb|CT of an asplenic patient]]
===CBC & Blood smear===
*Howell Jolly bodies
*Heinz Bodies
*Pappenheimer bodies
*Target cells
*Increased WBCs
*Increased platelets
 
===Presentation===
*Sickle-cell disease patient over the age of 8
*absent spleen on CT
*otherwise asplenic patient


===If Septic===
==Evaluation==
*Nonspecific symptoms
===Workup===
**cough
*CBC (elevated WBC, platelets)
**fever
*BMP, [[lactate]]
**increasing oxygen requirement
*[[CXR]]
**malaise
*Blood cultures, urine, wound cultures
**rash
*Peripheral blood smear
**nausea/vomiting
**Howell Jolly bodies
**constipation/diarrhea
**Heinz Bodies
**urinary symptoms
**Pappenheimer bodies
**rigors
**Target cells
*wound infection (perhaps from dog bite)


==Differential Diagnosis==
[[file:Splenectomyblood - Edited.jpg|thumb|Post-splenectomy blood smear demonstrating Howell-Jolly bodies and target cells.]]
*Bacterial infection (sepsis)
**Streptococcus pneumonia
**Haemophilus influenzae type B
**Neisseria meningitidis
**Capnocytophaga canimorsus
*Viral illness
 
==Workup==
*blood smear
*CBC
*BMP
*CXR
*x2 blood cultures
*UA w/ culture
*wound infection cultures
*additional imaging as necessary


==Management==
==Management==
===Sepsis===
===[[Sepsis]]===
*30mL/kg fluids
*30mL/kg fluids
*broad spectrum antibiotics appropriate for suspected infection
*broad spectrum antibiotics appropriate for suspected infection
*overwhelming majority of cases are from [[streptococcus]]


===Fever (no sepsis)===
===[[Fever]] (no sepsis)===
*treat empirically with broad spectrum antibiotics
*treat empirically with antibiotics
**amoxicillin-clavulanate: 90mg/kg amox per day in children divided into two doses; 875 mg/125 bid for adults
**[[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
**[[cefuroxime]]: 30mg/kg per day in children divided into two doses; 500mg BID for adults
**levofloxacin 750 mg once daily (adults or adolescents only)
**[[levofloxacin]] 750 mg once daily (adults or adolescents only)
**moxifloxacin 400 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)
**[[gemifloxacin]] 320 mg once daily (adults or adolescents only)


===Vaccination management===
===[[Vaccination]] management===
*4 doses of PCV13 before 15 months
*4 doses of PCV13 before 15 months
*PPSV23 at least 8 weeks after last PCV13, first at age 2
*PPSV23 at least 8 weeks after last PCV13, first at age 2
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*Hib conjugate vaccine for all unvaccinated patients above the age of 5 years
*Hib conjugate vaccine for all unvaccinated patients above the age of 5 years
*inactivated influenza vaccine yearly
*inactivated influenza vaccine yearly
*Neisseria meningitidis vaccine for asplenic adults
*Neisseria meningitidis vaccine for asplenic adults<ref name=Uptodate>Pasternick, Mark S et al.  Prevention of sepsis in the asplenic patient.  Uptodate. 2016.</ref>


===Prophylaxis===
===Prophylaxis===
*Daily Penicillin VK or amoxicillin
*Daily [[Penicillin VK]] or [[amoxicillin]]
*for children up to age of 5 or for 1 year following splenectomy
*for children up to age of 5 or for 1 year following splenectomy
*potentially up to age of 18 for highly immunocompromised individuals
*potentially up to age of 18 for highly immunocompromised individuals<ref name=NEJMcare>Lorry G. Rubin, M.D., and William Schaffner, M.D.
N Engl J Med 2014; 371:349-356July 24, 2014DOI: 10.1056/NEJMcp1314291</ref>


==Disposition==
==Disposition==
*to appropriate level of care for presenting illness
*Based on presenting complaint/illness (asplenia by itself is not an indication for admission)
*asplenia not an indication for admission
*Consider admitting asplenic patients presenting with fever


==See Also==
==See Also==
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==References==
==References==
Lorry G. Rubin, M.D., and William Schaffner, M.D. Care of the Asplenic Patient. 
N Engl J Med 2014; 371:349-356July 24, 2014DOI: 10.1056/NEJMcp1314291.
http://www.nejm.org/doi/full/10.1056/NEJMcp1314291
<references/>
<references/>
[[Category:Heme/Onc]] [[Category:ID]]

Latest revision as of 23:43, 30 September 2019

Background

Causes of asplenia

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)

Signs/symptoms of infection

Differential Diagnosis

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[1]

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[2]

Disposition

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

See Also

External Links

References

  1. ↑ Pasternick, Mark S et al. Prevention of sepsis in the asplenic patient. Uptodate. 2016.
  2. ↑ Lorry G. Rubin, M.D., and William Schaffner, M.D. N Engl J Med 2014; 371:349-356July 24, 2014DOI: 10.1056/NEJMcp1314291
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