Asplenic patient

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)

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

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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