Asplenia

Asplenia
ICD-10	D73.0, Q89.0
ICD-9	289.59, 759.01
OMIM	208530 %271400 208540

Asplenia Microchapters
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Epidemiology and Demographics
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Diagnosis
Diagnostic Study of Choice
History and Symptoms
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Treatment
Medical Therapy
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Primary Prevention
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Future or Investigational Therapies
Case Studies
Case #1
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief:

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Diagnosis

Diagnostic study of choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X-Ray Findings | Echocardiography and Ultrasound | CT-Scan Findings | MRI Findings | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Interventions | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Medical Therapy

Emergency Medical Management of suspected sepsis in Asplenic patient

Asplenia can cause sepsis and require immediate management:

• Children with asplenia for every febrile illness, must be seen by a physician immediately.
• Sepsis in individuals with asplenia or hyposplenia is a medical emergency as these patients can die within several hours of fever onset despite appearing well initially.
• Administration of antibiotic therapy should not be delayed and blood culture should be performed unless there is an obvious nonbacterial source.
• Ceftriaxone: 100 mg/kg/dose, (maximum 2 g/dose) should be given in all asplenic patients.
• Administer both ceftriaxone and vancomycin (60 mg/kg/day in divided doses every 6 h) in case of intermediate or high penicillin-resistant pneumococci.
• If the patient is treated in a clinic or office setting, refer immediately to the nearest emergency department.
• Clinical deterioration can be rapid even after antibiotic administratin so changes in antibiotics should be done after culture reports available.
• Vancomycin and ciprofloxacin can be used if the patient has an allergy to penicillin or cephalosporin. Changes in antibiotics should be done after culture reports available.
• According to the Surviving Sepsis Campaign guidelines, to avoid poor outcomes, patients suspected of sepsis should be started on antibiotics within 1 hour and as per standard sepsis guidelines, aggressive intravenous (IV) hydration should also be promptly initiated as a part of supportive care.
• Also, asplenic patients are prone to developing septic shock, they may require vasopressors to maintain their blood pressure and if patients develop respiratory failure, mechanical ventilation may be necessary for certain circumstances.

Surgery

The mainstay of treatment for asplenia is medical therapy and prevention.

Primary prevention

Vaccination

• Vaccination against these encapsulated bacteria is recommended to prevent asplenia patients from severe infection. Up to 87% of asplenic patients were found to have been infected with Streptococcus pneumoniae, one of the most common bacterial pathogen leading to infection in patients with asplenia.
• Vaccinations are also recommended before splenectomy and after the surgical removal. For those with functional asplenia or autosplenectomy, it is also advised to continue aggressive vaccination schedules. It is recommended that patients should be given the pneumococcal conjugate vaccine (PCV-13) 8 weeks in advance, as well as the pneumococcal polysaccharide vaccine (PPSV-23), Haemophilus influenzae type B vaccine (Hib), and the quadrivalent meningococcal conjugate vaccine 14 days before planned surgery for splenectomy.
• Apart from all these vaccines, patients should be encouraged to receive influenza vaccine, annual vaccination against the common strains of influenza.

Antibiotic Prophylaxis

• Only Immunizations do not protect against infections with encapsulated bacteria, antibiotic prophylaxis Should be given.
  • For children
    • All patients younger than five years of age should receive antibiotic prophylaxis.
    • Birth to three months: Escherichia coli, Klebsiella are of concern in this age group.
      • Amoxicillin or clavulanate 10 mg/kg/dose PO q12h, with penicillin VK 125 mg per dose PO q12h OR amoxicillin 10 mg/kg/dose q12h, as an alternative if not tolerated.
    • more than 3 months to five years
      • Penicillin VK 125 mg per dose PO q12h OR amoxicillin 10 mg/kg/dose PO q12h.
      • Liquid amoxicillin tastes better and may be better tolerated than liquid penicillin.
    • more than 5 years
      • Penicillin V 250 mg or 300 mg per dose q12h OR amoxicillin 250 mg per dose q12h.
      • For penicillin, 250 mg is a convenient dose for suspension but tablets are only available as 300 mg
• The infectious risk in asplenic patients is high during their entire life but it is highest during the first 2 years following splenectomy and the risk decreases over time.
• Along with vaccination, antibiotic prophylaxis should be given.
• Long term prophylactic therapy oral antibiotic penicillin V, or erythromycin in case of allergy, is required for at least 2 years after splenectomy to cover the period during which the infectious risk is highest.

Malaria Prophylaxis

• Asplenic and hyposplenic children must be advised of their increased risk of severe malaria and also take malaria prophylaxis as appropriate for their age and the type of malaria found in the area to which they are travelling and they should always seek travel advice.

Secondary prevention

Effective measures for the secondary prevention of asplenia include:

• Patient should carry an alert card or bracelet and an up-to-date vaccination record.
• Adult with asplenia, if unable to seek medical attention within 2 hours, should have access to preprescribed antibiotics which should be taken at fever onset.
• The risk of infection can be significantly reduced by using systematic, long-term approaches to care for asplenic patients.
• Patient and family education program that addresses the risk of infection in these at-risk patients.

Case Studies

Case #1

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