Asplenic patient

Background

Causes of asplenia

• Congenital
• Surgical
  • Previous hypersplenism
  • Sickle cell disease
  • Immune thrombocytopenic purpura
  • Hodgkin's lymphoma
  • Thalassemia
  • Hereditary spherocytosis
• Functional
  • Sickle cell disease

Asplenia increases risk of (and worsens course of)

• Pneumonia
• Sepsis/septicemia
• Infections from encapsulated bacteria
• Viral diseases

Clinical Features

Presentation

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

If Septic

• Nonspecific symptoms
  • cough
  • fever
  • increasing oxygen requirement
  • malaise
  • rash
  • nausea/vomiting
  • constipation/diarrhea
  • urinary symptoms
  • rigors
• wound infection (perhaps from dog bite)

Differential Diagnosis

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

Evaluation

Workup

• blood smear
• CBC
• BMP
• CXR
• x2 blood cultures
• UA w/ culture
• wound infection cultures
• additional imaging as necessary

CBC & Blood smear

• Howell Jolly bodies
• Heinz Bodies
• Pappenheimer bodies
• Target cells
• Increased WBCs
• Increased platelets

Management

Sepsis

• 30mL/kg fluids
• broad spectrum antibiotics appropriate for suspected infection

Fever (no sepsis)

• treat empirically with broad spectrum 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

• to appropriate level of care for presenting illness
• asplenia not an indication for admission

See Also

• Vaccination schedule
• Sepsis

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