View source for Asplenic patient

==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
**[[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)===
*[[Pneumonia]]
*[[Sepsis]]/septicemia
*[[Babesiosis]], [[Ehrlichiosis]]
*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]]

[[File:Asplenia.jpg|thumb|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

[[file:Splenectomyblood - Edited.jpg|thumb|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<ref name=Uptodate>Pasternick, Mark S et al.  Prevention of sepsis in the asplenic patient.  Uptodate. 2016.</ref>

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

==See Also==
*[[Vaccination schedule]]
*[[Sepsis]]

==External Links==

==References==
<references/>

[[Category:Heme/Onc]] [[Category:ID]]