Asplenic

Aka: Asplenic, Asplenia, Functional Asplenia, Asplenism, Hyposplenism, Hyposplenic, Postsplenectomy

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II. Causes: Hyposplenism or Asplenism

  1. Common Surgical Causes
    1. Splenectomy
    2. Partial Splenectomy
  2. Common Medical Causes
    1. Celiac Disease
    2. Cirrhosis
    3. Sickle Cell Anemia
    4. Vasculitis
    5. Systemic Lupus Erythematosus
    6. Bone Marrow Transplantation
    7. Splenic irradiation in Hodgkin's Disease
  3. Other Causes of Hyposplenism
    1. Cyanotic heart disease
    2. Ulcerative Colitis
    3. Whipple's Disease
    4. Chronic active hepatitis
    5. Acute Alcohol Abuse
    6. Hemoglobinopathy
    7. Primary Thrombocythemia
    8. Fanconi's Syndrome
    9. Malignant histiocytosis
    10. Rheumatoid Arthritis
    11. Grave's Disease
    12. Sarcoidosis
    13. Splenic arterial or venous Occlusion
    14. HIV Infection
    15. Total Parenteral Nutrition
    16. High dose Corticosteroids

III. Pathophysiology: High Risk Organisms

  1. Encapsulated Bacteria
    1. Streptococcus Pneumoniae
    2. Haemophilus Influenzae
    3. Neisseria Meningitidis
  2. Gram Negative Bacteria
    1. Capnocytophaga canimorsus (Dog Bites)
  3. Intraerythrocytic Parasites
    1. Plasmodia falciparum (Malaria)
    2. Babesia Microti (Babesiosis)
  4. Less common organisms
    1. Group B Streptococcus
    2. Enterococcus
    3. Bacteroides
    4. Salmonella
    5. Bartonella
    6. Plesiomonas shigelloides
    7. Eubacterium plauti
    8. Pseudomonas pseudomallei

IV. Diagnostics to identify Hyposplenism

  1. Step 1: History suggests possible Hyposplenism
    1. Known post-Splenectomy: See Management below
    2. Possible Hyposplenism: Go to Step 2
  2. Step 2: Peripheral Smear shows Howell-Jolly Bodies
  3. Step 3: Abdominal Ultrasound if smear positive
    1. Spleen absent
      1. See Management below
    2. Spleen present
      1. Radionuclide liver-Spleen scan
  4. Step 4: Radionuclide liver-Spleen scan
    1. Normal Uptake
      1. Normal splenic function
    2. Decreased or absent splenic uptake
      1. See management below

V. Management: Prevention

  1. Initial Immunizations
    1. Timing
      1. Preferred >14 days before elective splenectomy
      2. Otherwise administer at least 14 days after splenectomy
    2. Immunizations
      1. Pneumococcal Vaccine
        1. Prevnar 13 for children and adults
        2. PPV-23 (Pneumovax) for adults and children
          1. Follows Prevnar 13 by at least 8 weeks
          2. Repeat PPV-23 (Pneumovax) every 5 years (see below)
      2. Meningococcal Vaccine
        1. Quadrivalent Meningococcal Conjugate Vaccine or MCV4 (e.g. Menactra, Menveo)
          1. Two dose series (with 2 month interval) and
          2. Future boosters every 5 years
        2. Serotype B Meningococcal Vaccine (e.g. Trumenba, Bexsero)
          1. Recommended in addition to MCV4 for those over age 10 years
      3. Haemophilus B Conjugate Vaccine
        1. Primary Series in children (four doses)
        2. No guidelines on booster Immunization in Asplenic adults
  2. Repeat Immunizations
    1. Influenza Vaccine each year
    2. Repeat Pneumococcal Vaccine (PPV-23) after age 10 years
      1. Every 5 years for most Asplenic patients
      2. Every 3 years for early waning Antibody titers
        1. Hypogammaglobulinemia
        2. Sickle Cell Anemia
        3. Nephrotic Syndrome
        4. Chronic Renal Failure
    3. Repeat Quadrivalent Meningococcal Conjugate Vaccine or MCV4 (e.g. Menactra, Menveo)
      1. Every 5 years
  3. Documentation and Education
    1. Medic-Alert Bracelet
    2. Update medical record
      1. Vaccinations
      2. Asplenism
    3. Patient educated on infectious risks of Asplenism
      1. Immediate evaluation for febrile illness
      2. Notify dentists and doctors of Asplenic state
      3. Exposure risks
        1. Travel (Malaria)
        2. Tick Bites (Ehrlichia and Babesiosis)
        3. Dog Bite

VI. Management: Antibiotics for prophylaxis or as Stand-by at first signs of infection

  1. Antibiotics: Daily prophylaxis
    1. Amoxicillin
    2. Penicillin
    3. Trimethoprim-Sulfamethoxazole (Bactrim)
  2. Antibiotics: Stand-by Antibiotics
    1. Amoxicillin-Clavulanate
    2. Cefuroxime (Zinacef)
    3. Levofloxacin (Levaquin) - in adults
  3. Protocols
    1. Children with Asplenism or Hyposplenism
      1. Daily Prophylaxis
      2. Duration controversial (options below)
        1. First 2-5 years after splenectomy
        2. Continued until age 21 years
        3. Continue daily prophylaxis if history of Overwhelming Postsplenectomy Infection
    2. Adults with Asplenism or Hyposplenism
      1. Continue daily prophylaxis if history of Overwhelming Postsplenectomy Infection
      2. Standby Antibiotics taken at first signs infection (fever)
        1. Augmentin or
        2. Levofloxacin
      3. Immediate medical evaluation mandatory
        1. Well-appearing: Obtain cultures and continue Antibiotics for 7-10 days
          1. Consider 24 hour follow-up
        2. Suspect Sepsis: Admit immediately, culture and start IV broad spectrum Antibiotics
          1. See Overwhelming Postsplenectomy Infection

VII. Management: Acute Infection

  1. See Overwhelming Postsplenectomy Infection

VIII. References

  1. Pasternack (2018) UpToDate, Prevention of Sepsis in Asplenic patient, accessed 3/1/2018
  2. Brigden (2001) Am Fam Physician 63(3):499-506 [PubMed]
  3. DeRossi (1996) J Am Dent Assoc 127:1359-63 [PubMed]
  4. Doll (1987) South Med J 80:999-1006 [PubMed]
  5. Rubin (2020) N Engl J Med 371(4): 349-56 [PubMed]
  6. Sumaraju (2001) Infect Dis Clin North Am 15(2):551-65 [PubMed]
  7. (1996) BMJ 312:430-4 [PubMed]

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