Dangers of Infection in the Splenectomy Patient

Authors: Dilani Weerasuriya, MD (EM Attending Physician, WellStar Health System) and Edward Stettner, MD (EM Attending Physician / Program Director, WellStar Kennestone Regional Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Case:

A 63-year-old male presents for headache and a fever that have been present for 2 days. He denies any medical problems. Vital signs include blood pressure of 108/79, heart rate of 120, temperature of 102.3, respiratory rate of 20, and pulse oxygenation of 100%. On exam, he has neck pain with stiffness and a large scar across his abdomen. He reports being in a motorcycle accident decades ago and having his spleen removed. Does his splenectomy affect your management? What is your next step?

Background

Approximately 1 million people live in the U.S. without a spleen.¹ While the majority of these patients have undergone surgical excision, some are functionally asplenic for other reasons.  Splenectomy may be performed due to trauma, hereditary spherocytosis, immune thrombocytopenic purpura, hypersplenism, and sickle cell anemia.¹ Other causes of functional asplenia include infarctions, such as those seen in sickle cell disease, and congenital causes, such as isolated congenital hyposplenia and Ivemark’s syndrome (a syndrome with multiorgan dysfunction and asplenia). Because the causes of asplenia are so diverse, the presentations of sepsis with asplenia can be equally diverse and even subtle.

Why are asplenic patients more prone to infection? Why are certain bacteria more dangerous?

The spleen functions as a component of the immune system, filtering blood and assisting with antibody production.² Splenic macrophages are a crucial defense against encapsulated organisms. As a result, patients who lack a functional spleen are at increased risk for significant infection, especially by encapsulated bacterial organisms. Parasitic infections affect asplenic patients more severely because they do not have a competent spleen to filter defective erythrocytes, such as erythrocytes that contain parasites. Mortality rates from an overwhelming post-splenectomy infection range from 50% to 70%. However, with early identification and management, the mortality rate can be as low as 10%.⁸

What kind of infections do asplenic patients contract?  

Which asplenic patients are more prone to infection?

• Elderly and male patients have a higher incidence of noncompliance with protocols and vaccinations that could prevent sepsis.⁶
• The highest risk for fulminant sepsis is in lymphoma patients who received chemotherapy and radiation and in children who had splenectomies as infants.^2,4
• The highest risk of infection is 90 days after splenectomy, but it remains significantly higher for the first 2 years following surgery.^5,6

Important items in the history and review of systems…

• Are they up to date on their vaccines? Do they follow the CDC recommendations of vaccines against Haemophilus influenza type B, meningococcemia, influenza, and 23-valent pneumococcus?⁸
• If they had a splenectomy, when was it done?
• Have they noticed any new rashes? (potential indicator of DIC or meningococcemia)⁸
• Have they been on any recent antibiotics, steroids, or antipyretics? (some patients are on daily prophylactic antibiotics)

• Have they been bitten by any dogs or cats recently?
• Any recent travel?
• Any night sweats?
• Any respiratory complaints?
• Any neurological complaints?

Lab evaluation

• Look for signs of meningismus.
• Look for signs of DIC.
• The blood count differential may show either an elevated or depressed granulocyte count.²
• Howell-Jolly bodies are often seen on blood smears. (see picture)

Picture by Peter Maslak – https://imagebank.hematology.org/image/3677/howelljolly-bodies–1?type=upload

• Platelet counts and clotting times may suggest disseminated intravascular coagulation (decreased platelets, increased clotting times).
• A chest xray should be ordered on most of these patients.
• Have a low threshold for lumbar puncture with gram stains. Asplenic patients are at higher risk of meningitis, with increased morbidity and mortality.⁷

Management

Do not delay antibiotics to perform any diagnostic testing. Asplenic patients can decompensate quickly, therefore any possible infection should be treated with antibiotics rapidly. Their mortality rate may be decreased from 70% to 10% with effective and early management.⁸

Broad spectrum antibiotics are appropriate, and possible selections include:

Adults²

• Vancomycin (20 mg/kg IV, with a maximum of 2 grams per dose)
• Meningitis doses of
  • Ceftriaxone (2 g) or
  • Cefotaxime (2 g) or if beta-lactam allergic
  • Moxifloxacin 400 mg IV

Children²

• Vancomycin (15 mg/kg, maximum dose of 1 gram per dose)
• Ceftriaxone (50 mg/kg, maximum dose of 2 grams) or
  • Cefotaxime (300 mg/kg/day given TID or QID, with a maximum of 12 grams per day)
  • If beta-lactam allergic – fluoroquinolone after discussion with family members of the risks – levofloxacin 10 mg/kg or moxifloxacin 5 mg/kg

Dexamethasone should be administered if considering meningitis

Pearls and Pitfalls

• Ask all patients with a surgical scar near their spleen if they had a splenectomy.
• Consider treating patients who are at risk for functional asplenia as if they are asplenic (for example, patients with hemoglobinopathies or bone marrow transplants).
• Ask what antibiotics, steroids, and vaccines they have received recently.
• Even if an asplenic patient is afebrile in the emergency department, but reports a fever at home, consider performing a complete sepsis work up in the emergency department.
• Asplenic patients are at increased risk for encapsulated organisms, parasites, DIC, and meningitis.
• Evaluate for DIC prior to performing a lumbar puncture, if one is indicated.
• Streptococcus pneumoniae is still the most common cause of sepsis and death in these patients.
• Asplenic patients have little reserve and high mortality. Give antibiotics and start aggressive hypotension management early.

Case Resolution:

The patient’s lumbar puncture is consistent with bacterial meningitis. He had already been started on appropriate antibiotics and IV fluid resuscitation. His wife states that he has not had any follow up since his initial surgery and had not been receiving vaccines. Despite early antibiotics, he requires a central line and vasopressors. He is admitted to the ICU.

References / Further Reading:

1. Dragomir, Petrescu, Manga, Calin, Vasilescu. Patients after splenectomy: old risks and new perspectives. Chirugia. 111 (5), 2016.
2. Pasternack, Weller, Edwards, Thorner. Clinical features and management of sepsis in the asplenic patient. Uptodate.
3. Holdsworth, Irving, Cuschieri. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg. 1991; 78 (9): 1031.
4. Weitzman, Aisenberg. Fulminant sepsis after the successful treatment of Hodgkin’s disease. Am J Med. 1977; 62(1): 47.
5. Thomsen, Schoonen, Farkas, Riis, Jacobsen, Fryzek, Sorensen. Risk for hospital contact with infection in patients with splenectomy: a population-based cohort study. Ann Intern Med. 2009; 151 (8): 546.
6. Kotsanas, Al-Souffi, Waxman, King, Polkinghorne, Woolley. Adherence to guidelines for prevention of postsplenectomy sepsis. Age and sex are risk factors: A five-year retrospective review. Anz J Surg. 2006 Jul;76(7):542-7.
7. Adriani, Brouwer, Van Der Ende, Van de Beek. Bacterial meningitis in adults after splenectomy and hyposplenic states. Mayo Clin Proc. 2013 Jun; 88(6):571-8.
8. Morgan, Tomich. Overwhelming post-splenectomy infection (OPSI): A case report and review of the literature. The Journal of Emergency Medicine. 2012; 43 (4): 758-763.