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
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
- 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
Workup
- blood smear
- CBC
- BMP
- CXR
- x2 blood cultures
- UA w/ culture
- wound infection cultures
- additional imaging as necessary
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
External Links
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.