Asplenic patient: Difference between revisions
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===Presentation=== | ===Presentation=== | ||
*Sickle-cell disease patient over the age of 8 | *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)=== | ||
| Line 23: | Line 23: | ||
*[[Sepsis]]/septicemia | *[[Sepsis]]/septicemia | ||
*[[Babesiosis]], [[Ehrlichiosis]] | *[[Babesiosis]], [[Ehrlichiosis]] | ||
*Infections from encapsulated bacteria (e.g. [[Strep | *Infections from encapsulated bacteria (e.g. [[Strep pneumo]], [[H. influenzae]], [[Neisseria meningitidis]]) | ||
*Viral illnesses | *[[viral syndrome|Viral illnesses]] | ||
===Signs/symptoms of infection=== | ===Signs/symptoms of infection=== | ||
*[[ | *[[Cough]], [[fever]], rigors, malaise | ||
*[[ | *[[Nausea/vomiting]], [[constipation]]/[[diarrhea]] | ||
* | *[[dysuria|Urinary symptoms]] | ||
*wound infection | *wound infection | ||
*[[ | *[[Rash]] | ||
* | *[[Hypoxia|Increased oxygen requirement]], [[tachycardia]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Bacterial infection ([[sepsis]]) | *[[bacterial disease|Bacterial infection]] ([[sepsis]]) | ||
**[[Streptococcus]] pneumonia | **[[Streptococcus]] pneumonia | ||
**[[Haemophilus influenzae]] type B | **[[Haemophilus influenzae]] type B | ||
| Line 41: | Line 41: | ||
**[[Capnocytophaga canimorsus]] | **[[Capnocytophaga canimorsus]] | ||
**[[Bordetella holmesii]] | **[[Bordetella holmesii]] | ||
*Viral illness | *[[Viruses|Viral illness]] | ||
[[File:Asplenia.jpg|thumb|CT of an asplenic patient]] | [[File:Asplenia.jpg|thumb|CT of an asplenic patient]] | ||
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===Workup=== | ===Workup=== | ||
*CBC (elevated WBC, platelets) | *CBC (elevated WBC, platelets) | ||
*BMP, lactate | *BMP, [[lactate]] | ||
*[[CXR]] | *[[CXR]] | ||
*Blood cultures, urine, wound cultures | *Blood cultures, urine, wound cultures | ||
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**[[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 | ||
Latest revision as of 23:43, 30 September 2019
Background
Causes of asplenia
- Congenital
- Prior splenectomy for:
- Previous hypersplenism
- Sickle cell disease
- Immune thrombocytopenic purpura, TTP, autoimmune hemolytic anemia
- Hodgkin's lymphoma
- Thalassemia
- Hereditary spherocytosis
- Splenic injury (rupture/hemorrhage)
- Functional
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, Neisseria 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
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
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