Infectious Disease Compendium

Splenectomy Infections

Diagnosis

Spleen gone. Usually not a subtle finding on history or exam, Howell-Jolie bodies can be a hint on the smear.

Epidemiologic Risks

Trauma (you do wear your seat belt?), sloppy surgeon, the following incomplete list of diseases that act as if they are asplenic: Alcoholism, amyloidosis, autoimmune hemolytic anemia, biliary cirrhosis, bone marrow transplantation, celiac disease, chronic active hepatitis, chronic graft vs. host reaction, chronic myelogenous leukemia, collagenous colitis, essential thrombocythemia, Graves' disease, hairy cell leukemia, hashimoto's thyroiditis, hemangiosarcoma of the spleen, hemophilia, hematologic diseases, hereditary spherocytosis, Hodgkin's disease, idiopathic thrombocytopenic purpura, non-hodgkin's lymphoma, ovarian carcinoma, portal hypertension, rheumatoid arthritis, right sided heart failure, sarcoidosis, Sjögren's syndrome, splenic irradiation, systemic lupus erythematosus, thalassemia, ulcerative colitis, Whipple's disease.

It is not that they get more infections, but that they get worser infections, especially with encapsulated organisms.

The risk is highest 90 days after loss of spleen, but the life time risk for infection remain 4.6 times higher than the general population (PubMed).

Microbiology

Streptococcus pneumoniae the #1 cause of severe sepsis after splenectomy (Pubmed), Haemophilus influenzae, Salmonella, Capnocytophagia canimorsus, Malaria, Babesia, Meningococcus.

and more. Splenectomy is associated with all kinds of badness:

"Splenectomized patients had an increased risk of being hospitalized for pneumonia, meningitis, and septicemia (rate ratios=1.9­3.4); deep venous thrombosis and pulmonary embolism (rate ratio=2.2); certain solid tumors: buccal, esophageal, liver, colon, pancreas, lung, and prostate (rate ratio =1.3­1.9); and hematologic malignancies: non­Hodgkin lymphoma, Hodgkin lymphoma, multiple myeloma, acute myeloid leukemia, chronic lymphocytic leukemia, chronic myeloid leukemia, and any leukemia (rate ratio =1.8­6.0). Also there was an increased risk of death due to pneumonia and septicemia (rate ratio =1.6­3.0); pulmonary embolism and coronary artery disease (rate ratio =1.4­4.5); any cancer, liver, pancreas, and lung cancer, non­Hodgkin lymphoma, Hodgkin lymphoma, and any leukemia (rate ratio =1.3­4.7). Many of the observed risks were increased >10 years after splenectomy (PubMed)."

Empiric Therapy

Vancomycin PLUS third generation cephalosporins OR carbapenems OR penicillin/beta-lactamase inhibitors OR quinolone.

Pearls

There is this neat thing out called the vaccine and it exists for both Streptococcus pneumoniae and Haemophilus influenzae. Perhaps it would be nice to give the vaccine BEFORE you remove that spleen.

Rants

I remain amazed at the number of splenectomy patients who have not been warned that they can get sicker than stink faster than a republican can go to war. Tell your patient about the potential seriousness of a fever and give them the damn vaccine.