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Post splenectomy infection

Post splenectomy infection. Dr. M. Shahparianpour. Spleen. consists of the capsule and trabeculae which enclose the pulp. 3 zones of the pulp a. White pulp – lymph node; contains lymphocytes, macrophages, and plasma cells in a reticular network

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Post splenectomy infection

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  1. Post splenectomy infection Dr. M. Shahparianpour

  2. Spleen

  3. consists of the capsule and trabeculae which enclose the pulp. 3 zones of the pulp a. White pulp – lymph node; contains lymphocytes, macrophages, and plasma cells in a reticular network b. Red pulp – consists of the cord and sinuses; contains the cellular elements of the blood c. Marginal zone – poorly defined vascular space between pulps; contains sequestered foreign material and plasma as well as abnormal cellular elements

  4. histology

  5. The role of the spleen in the prevention of bacterial infections

  6. It acts as an endothelial filtration organ for bacteria and other foreign material through: phagocytosis and the production of opsonins including antigen-specific IgM, alternate complement components, properdin, and tuftsin • One of its most important immune functions is responding to blood-borne particulate antigens in the nonimmune host. The spleen provides the most effective primary IgM response to encapsulated bacteria

  7. There also seems to be a relationship between the quantity and quality of spleen and protection against sepsis: splenic function after subtotal splenectomy for splenic injury is preserved and may be adequate to prevent severe postsplenectomy sepsis The propensity for pneumococcal infections in patients with sickle cell disease underscores the importance of qualitative splenic function to protect against sepsis

  8. Etiology of asplenia and hyposplenia

  9. Asplenia refers to the absence of the spleen. • The most common cause of asplenia is surgical removal of the spleen: Hypersplenism accounts for up to 50% of splenectomies, whereas trauma accounts for 10% to 30%

  10. A rare cause of asplenia is congenital agenesis of the spleen. • This may occur as an isolated finding or as part of a syndrome often associated with cardiovascular abnormalities, such as Ivemark’s syndrome. Hyposplenism refers to a poorly functioning, but intact spleen

  11. Functional asplenia

  12. The risk of developing severe infection remains a significant complication of asplenia (surgical splenectomy or congenital asplenia) and hyposplenia, especially in children under the age of 5 years

  13. Splenicsalvage methods (eg, partial splenectomy) are practiced with specific indications, the goal being to preserve some of the splenic immune function. • Whether partial splenectomy renders the same risk of developing overwhelming postsplenectomy sepsis (OPSS) as total splenectomy and whether the same preventative measures should be taken, remain unclear.

  14. Definition of OPSI OPSI may have a short prodrome with non-specific symptoms Evolve into septic shock and DIC Clinical course measured in hours rather than days Fever most common – most report rigors 1 - 2 days prior to presentation In adults OPSI usually cryptic infection without primary source

  15. It is well known that asplenia or hyposplenia convey an increased lifetime risk of developing severe infections to an affected individual, regardless of: age, the cause of asplenia or hyposplenia, in the case of splenectomy, the duration of time from removal of the spleen

  16. the incidence seems to be related to age and underlying disease : Splenectomized children under the age of 15 years are at greater risk of developing OPSS than adults • The incidence of OPSS is higher in children with underlying hemoglobinopathies (thalassemia major and sickle cell disease) and hereditary spherocytosis than in those who undergo splenectomy because of trauma

  17. Risk of OPSI can be stratified according to underlying disease

  18. Risk of post splenectomy sepsis low but carries high risk of death (50-80%) If patients are educated to seek attention immediately may be reduced to about 10% More than 50% who die do so within 48 hours of admission

  19. Children: 1/175 patient years • Adults: 1/400~500 patient years • Highest risk at first few years • 1/3 at first year • 1/2 at first 2 years • However, 1/3 after first 5 years Can happen even 20 years after splenectomy

  20. Clinical manifestations Fever Any fever must be viewed as possible PSS • Bacteremia • Coagulopathy • Purpura, petechiae • Meningitis • Headache, neck stiffness, seizure • Respiratory symptoms • Cough, dyspnea, respiratory failure • GI symptoms • Nausea, vomiting, diarrhea, GI bleeding • Shock

  21. The mortality rate of sepsis associated with asplenia or hyposplenia remains high; death occurs in 50% to 70% of those afflicted • Mortality rates are also age related, with the highest rates reported in those children less than 2 years of age

  22. Common pathogens • Encapsulated pathogen • Streptococcus pneumoniae(50~60 %) • No particular serotype is more common • Haemophilusinfluezae(20~30 %) • Neisseria spp.(10~20 %) • Other uncommon pathogens: • Capnocytophagacanimorsus • Common flora in oral cavity of dogs and cats • Bordetellaholmesii

  23. Capnocytophagacanimorsus

  24. LAB • CBC • Blood smear • DIC profile • Lumbar puncture • CXR • Blood culture

  25. Management • Braod-spectrum antibiotics • Based on expert opinion • Must cover: • penicillin-resistant pneucoccus • beta-lactamase producing H.influenzae • General suggestion Ceftriaxone + Vancomycin Levofloxacin + Vancomycin • Life-support measures • H/D or CVVH for ARF • Ventilator • Inotropic agents • Fluid

  26. Prevention Avoid unnecessary splenectomy • Immunization • Timing • 14 days before splenectomy • 14 days after splenectomy (not immediately) • Pneumococcal vaccine • PPV-23 for adults • PCPV-7 for children and some adults • Haemophilus B vaccine • Meningococcal vaccine • Re-immunization • Other vaccines: influenza vaccine

  27. Antibiotic prophylaxis • Daily penicillin • Reduce incidence by half • Reduce mortality by 80 percents • Life-long or 3~5years? • Post PSS patients • Abx for fever • On hand • Empirical: Augmentin, Cefuroxine, fluoroquinolones When fever, Take the drug and go to doctor without delay • Abx for dental procedures Not recommended for no obvious advantage

  28. Absent or dysfunctional spleen in adults Immunisation Travel † Antibiotics Antibiotic prophylaxis (adult dose) Penicillin V 500mg b.d. Amoxycillin 500mg bd (Erythromycin 250mg od if penicillin allergy) HiB Vaccine Previously non immunised adults should receive a single dose of vaccine. Pneumococcal vaccine Polysaccharide vaccine (Pneumovax). Avoid in pregnancy. Meningitis C vaccine Previously non immunised adults should receive a single dose of vaccine Influenza Annual Influenza vaccine Anti-malarials if travelling to endemic areas Meningitis A+C,W135,Y if appropriate Antibiotics‡ Check antibodies 4/52 post vaccination Antibiotic cover 3 day supply of Amoxycillin should be kept by the patient with instructions to take 1gm at first sign of infection and 500mg tds thereafter and to seek immediate medical attention. Poor response revaccinate and re-test at 4/52 Good response recheck antibody titre in 1 year If poor response give conjugate (Prevenar) if not already given. †Discuss with Adult Infectious Disease team ‡Antibiotic prophylaxis may need altering depending upon local resistance.

  29. Malaria • Lack of splenic clearance of leads to high parasitaemia Increased risk of fulminant malaria

  30. Antibiotic Prophylaxis 1. All patients, regardless of underlying condition, should be on lifelong antibiotic prophylaxis. This should be either Penicillin V or Amoxycillin, with a preference for Penicillin V. Adult doses: Penicillin V 500 mg b.d. Amoxycillin 500 mg o.d. 2. For penicillin allergic patients, Erythromycin 250 mg b.d. should be used. 3. Patients travelling to areas where penicillin-resistant pneumococci have been identified should be switched from Penicillin V to Amoxycillin before travelling and for one week after return.

  31. Immunization 4. Asplenia in itself is not a contraindication to routine immunization. Normal inoculations, including live vaccines, can be given safelyto adults with absent or dysfunctional spleens. 5. All splenectomised patients and those with functional hyposplenism should receive pneumococcal immunisation; Haemophilus influenzae type B [Hib] conjugate vaccine and conjugated meningococcal C vaccine [MenC] as soon as possible. For pneumococcal vaccination the 23-polyvalent pneumococcal vaccine [Pneumovax] should be used.

  32. THANKS FOR YOUR ATTENTIONS

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