Asplenic patient: Difference between revisions

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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]]
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*Functional
*Functional
**[[Sickle cell disease]]
**[[Sickle cell disease]]
===Asplenia increases risk of (and worsens course of)===
*[[Pneumonia]]
*[[Sepsis]]/septicemia
*Infections from encapsulated bacteria
*Viral diseases


==Clinical Features==
==Clinical Features==
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*otherwise asplenic patient
*otherwise asplenic patient


===If Septic===
===Asplenia increases risk of (and worsens course of)===
*Nonspecific symptoms
*[[Pneumonia]]
**[[cough]]
*[[Sepsis]]/septicemia
**[[fever]]
*Infections from encapsulated bacteria
**increasing oxygen requirement
*Viral illnesses
**malaise
 
**[[rash]]
===Signs/symptoms of infection===
**[[nausea/vomiting]]
*[[cough]], [[fever]], rigors, malaise
**[[constipation]]/[[diarrhea]]
*[[nausea/vomiting]], [[constipation]]/[[diarrhea]]
**urinary symptoms
*urinary symptoms  
**rigors
*wound infection
*wound infection (perhaps from dog bite)
*[[rash]]
**increased oxygen requirement, tachycardia


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
*CBC
*CBC (elevated WBC, platelets)
*BMP
*BMP, lactate
*CXR
*CXR
*Blood cultures x2
*Blood cultures, urine, wound cultures
*UA w/ culture
*Wound culture, if present
*Peripheral blood smear
*Peripheral blood smear
**Howell Jolly bodies
**Howell Jolly bodies
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**Pappenheimer bodies
**Pappenheimer bodies
**Target cells
**Target cells
**Increased WBCs
**Increased platelets


[[file:Splenectomyblood - Edited.jpg|thumb|Post-splenectomy blood smear demonstrating Howell-Jolly bodies and target cells.]]
[[file:Splenectomyblood - Edited.jpg|thumb|Post-splenectomy blood smear demonstrating Howell-Jolly bodies and target cells.]]
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===[[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

Revision as of 16:01, 5 September 2016

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)

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

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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