Asplenic patient: Difference between revisions
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===Causes of asplenia=== | ===Causes of asplenia=== | ||
*Congenital | *Congenital | ||
* | *Prior splenectomy for: | ||
**Previous hypersplenism | **Previous hypersplenism | ||
**[[Sickle cell disease]] | **[[Sickle cell disease]] | ||
**[[Immune thrombocytopenic purpura]] | **[[Immune thrombocytopenic purpura]], [[TTP]], [[autoimmune hemolytic anemia]] | ||
**[[Hodgkin's lymphoma]] | **[[Hodgkin's lymphoma]] | ||
**[[Thalassemia]] | **[[Thalassemia]] | ||
**[[Hereditary spherocytosis]] | **[[Hereditary spherocytosis]] | ||
**[[Splenic injury]] (rupture/hemorrhage) | |||
*Functional | *Functional | ||
**[[Sickle cell disease]] | **[[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)=== | ===Asplenia increases risk of (and worsens course of)=== | ||
*[[Pneumonia]] | *[[Pneumonia]] | ||
*[[Sepsis]]/septicemia | *[[Sepsis]]/septicemia | ||
*Infections from encapsulated bacteria | *[[Babesiosis]], [[Ehrlichiosis]] | ||
*Viral | *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== | ==Differential Diagnosis== | ||
*Bacterial infection ([[sepsis]]) | *[[bacterial disease|Bacterial infection]] ([[sepsis]]) | ||
**[[Streptococcus]] pneumonia | **[[Streptococcus]] pneumonia | ||
**[[Haemophilus influenzae]] type B | **[[Haemophilus influenzae]] type B | ||
| Line 44: | Line 41: | ||
**[[Capnocytophaga canimorsus]] | **[[Capnocytophaga canimorsus]] | ||
**[[Bordetella holmesii]] | **[[Bordetella holmesii]] | ||
*Viral illness | *[[Viruses|Viral illness]] | ||
[[File:Asplenia.jpg|thumb|CT of an asplenic patient]] | |||
==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
*CBC | *CBC (elevated WBC, platelets) | ||
*BMP | *BMP, [[lactate]] | ||
*CXR | *[[CXR]] | ||
*Blood cultures | *Blood cultures, urine, wound cultures | ||
*Peripheral blood smear | *Peripheral blood smear | ||
**Howell Jolly bodies | **Howell Jolly bodies | ||
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**Pappenheimer bodies | **Pappenheimer bodies | ||
**Target cells | **Target cells | ||
[[file:Splenectomyblood - Edited.jpg|thumb|Post-splenectomy blood smear demonstrating Howell-Jolly bodies and target cells.]] | |||
==Management== | ==Management== | ||
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*30mL/kg fluids | *30mL/kg fluids | ||
*broad spectrum antibiotics appropriate for suspected infection | *broad spectrum antibiotics appropriate for suspected infection | ||
*overwhelming majority of cases are from [[streptococcus]] | |||
===[[Fever]] (no sepsis)=== | ===[[Fever]] (no sepsis)=== | ||
*treat empirically with | *treat empirically with antibiotics | ||
**[[amoxicillin-clavulanate]]: 90mg/kg amox per day in children divided into two doses; 875 mg/125 | **[[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 | **[[cefuroxime]]: 30mg/kg per day in children divided into two doses; 500mg BID for adults | ||
**[[levofloxacin]] 750 mg once daily (adults or adolescents only) | **[[levofloxacin]] 750 mg once daily (adults or adolescents only) | ||
**[[moxifloxacin]] 400 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) | **[[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 | ||
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*Hib conjugate vaccine for all unvaccinated patients above the age of 5 years | *Hib conjugate vaccine for all unvaccinated patients above the age of 5 years | ||
*inactivated influenza vaccine yearly | *inactivated influenza vaccine yearly | ||
*Neisseria meningitidis vaccine for asplenic adults | *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=== | ===Prophylaxis=== | ||
*Daily [[Penicillin VK]] or [[amoxicillin]] | *Daily [[Penicillin VK]] or [[amoxicillin]] | ||
*for children up to age of 5 or for 1 year following splenectomy | *for children up to age of 5 or for 1 year following splenectomy | ||
*potentially up to age of 18 for highly immunocompromised individuals | *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== | ==Disposition== | ||
*Based on presenting complaint/illness (asplenia by itself is not an indication for admission) | *Based on presenting complaint/illness (asplenia by itself is not an indication for admission) | ||
*Consider admitting asplenic patients presenting with fever | |||
==See Also== | ==See Also== | ||
| Line 103: | Line 103: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Heme/Onc]] [[Category:ID]] | |||
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