Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato-Oncology task force

Bacterial meningitis in adults after splenectomy and hyposplenic states

OBJECTIVE

To examine the occurrence, disease course, prognosis, and vaccination status of patients with community-acquired bacterial meningitis with a history of splenectomy or functional hyposplenia.

PATIENTS AND METHODS

Patients with bacterial meningitis proven by cerebrospinal fluid culture were prospectively included in a nationwide cohort study between March 1, 2006, and September 1, 2011. Splenectomy or diseases associated with functional hyposplenia were scored for all patients. Vaccination status, clinical features, and outcome of patients with a history of splenectomy or functional hyposplenia were analyzed and compared with patients with normal spleen function.

RESULTS

Twenty-four of 965 patients (2.5%) had an abnormal splenic function: 16 had a history of splenectomy and 8 had functional hyposplenia. All patients had pneumococcal meningitis. Pre-illness vaccination status could be retrieved for 19 of 21 patients (90%), and only 6 patients (32%) were adequately vaccinated against pneumococci. Pneumococcal serotype was known in 21 patients; 52% of pneumococcal isolates had a serotype included in the 23-valent vaccine. Vaccine failure occurred in 3 patients. Splenectomized patients more often presented with signs of septic shock compared with patients with a normal spleen (63% vs 24%; P=.02). Outcome was unfavorable in 14 patients (58%), and 6 patients died (25%).

CONCLUSION

Splenectomy or functional hyposplenia is an uncommon risk factor for bacterial meningitis but results in a high rate of mortality and unfavorable outcome. Most patients were not adequately vaccinated against Streptococcus pneumoniae.

Spleen-preserving distal pancreatectomy with and without splenic vessel ligation: a systematic review

BACKGROUND

Splenic preservation during a distal pancreatectomy (SPDP) may be performed with splenic vessel ligation, known as Warshaw's Technique (WT) or splenic vessel preservation (SVP). The consensus on which approach is best is divided. A systematic review of evidence in the literature was undertaken with the aim of analysing the merits and disadvantages of both WT and SVP.

METHODS

A systematic search of medical literature from 1985-2011 was undertaken to identify all comparative studies and case series on SPDP. Non-English papers, series with < 5 patients, technical reports and reviews were excluded. The remaining articles were reviewed considering the study design, surgical technique, outcomes and complications.

RESULTS

In 23 relevant studies, 356 patients underwent WT and 572 underwent SVP. In WT patients, the mean operating time (160 versus 215 min, P < 0.001), mean estimated blood loss (301 versus 390 ml, P < 0.001) and length of stay (8 versus 11 days, P < 0.001) was significantly less than the SVP patients, respectively. Considering complications, splenic infarction and splenectomy occurred more frequently in WT patients (P < 0.05).

DISCUSSION

WT is technically easier to perform than SVP but has a higher incidence of subsequent splenectomies. Surgeons should be able to perform both procedures and tailor the technique according to the patient.

Spontaneous spleen rupture in a teenager: an uncommon cause of acute abdomen

Spontaneous spleen rupture is a rare complication of infectious diseases and it can become a potentially life-threatening condition if not diagnosed in time. A 17-year-old Greek female presented to the ER due to acute abdominal pain, mainly of the left upper quadrant. She had no recent report of trauma. The patient was pale, her blood pressure was 90/70 mmHg, and her pulse was 120 b/min. Clinical examination of the abdomen revealed muscle contraction and resistance. The patient was submitted to an ultrasound of the upper abdomen and to a CT scanning of the abdomen that revealed an extended intraperitoneal hemorrhage due to spleen rupture. Due to the patient's hemodynamic instability, she was taken to the operation room and splenectomy was performed. Following a series of laboratory examinations, the patient was diagnosed to be positive for current cytomegalovirus infection. The postoperative course was uneventful, and in a two year follow-up the patient is symptom-free. Spontaneous spleen rupture due to Cytomegalovirus infection is a rare clinical entity, described in few case reports in the world literature and should always be taken into consideration in differential diagnosis of acute abdomen, especially in adolescents with no recent report of trauma.

Is it worth investigating splenic function in patients with celiac disease?

Celiac disease, an immune-mediated enteropathy induced in genetically susceptible individuals by the ingestion of gluten, is the most frequent disorder associated with splenic hypofunction or atrophy. Defective splenic function affects more than one-third of adult patients with celiac disease, and it may predispose to a higher risk of infections by encapsulated bacteria and thromboembolic and autoimmune complications, particularly when celiac patients have concomitant pre-malignant and malignant complications (refractory celiac disease, ulcerative jejunoileitis and enteropathy-associated T-cell lymphoma). However, the clinical management of patients with celiac disease does not take into account the evaluation of splenic function, and in patients with high degree of hyposplenism or splenic atrophy the prophylactic immunization with specific vaccines against the polysaccharide antigens of encapsulated bacteria is not currently recommended. We critically re-evaluate clinical and diagnostic aspects of spleen dysfunction in celiac disease, and highlight new perspectives in the prophylactic management of infections in this condition.

Current management of immune thrombocytopenia

Immune thrombocytopenia (ITP) is an autoimmune-mediated condition that results from antibody-mediated destruction of platelets and impaired megakaryocyte platelet production. ITP patients exhibit severe thrombocytopenia and are at risk for significant hemorrhage. Few randomized trials exist to guide management of patients with ITP. Ultimately, each patient requires an individualized treatment plan that takes into consideration the platelet count, bleeding symptoms, health-related quality of life, and medication side effects. This article provides an up-to-date review of management strategies drawing on links between the expanding amounts of clinical trial data and associated biology studies to enhance understanding of the disease heterogeneity with regard to the complex pathogenesis and response to treatment.

The need for guidelines in asplenic patients undergoing total joint arthroplasty: a case report

There are currently no guidelines for splenectomy patient undergoing total joint arthroplasty. We present a case history of a 63-year-old man with a history of splenectomy that underwent a total knee arthroplasty with standard intravenous antibiotic prophylaxis. Two weeks postoperatively, he developed a prosthetic joint infection and followed the standard antimicrobial management with intravenous and oral antibiotics prior to having revision surgery. We propose that there are guidelines to properly manage these patients in the pre- and perioperative setting following an orthopaedic procedure.

Contemporary management of primary immune thrombocytopenia in adults

Immune thrombocytopenia (ITP) comprises a syndrome of diverse disorders that have in common immune-mediated thrombocytopenia, but that differ with respect to pathogenesis, natural history and response to therapy. ITP may occur in the absence of an evident predisposing etiology (primary ITP) or as a sequela of a growing list of associated conditions (secondary ITP). Primary ITP remains a diagnosis of exclusion and must be differentiated from non-autoimmune etiologies of thrombocytopenia and secondary causes of ITP. The traditional objective of management is to provide a hemostatic platelet count (> 20-30 × 10(9) L(-1) in most cases) while minimizing treatment-related toxicity, although treatment goals should be tailored to the individual patient and clinical setting. Corticosteroids, supplemented with either intravenous immune globulin G or anti-Rh(D) as needed, are used as upfront therapy to stop bleeding and raise the platelet count acutely in patients with newly diagnosed or newly relapsed disease. Although most adults with primary ITP respond to first-line therapy, the majority relapse after treatment is tapered and require a second-line approach to maintain a hemostatic platelet count. Standard second-line options include splenectomy, rituximab and the thrombopoietin receptor agonists, romiplostim and eltrombopag. Studies that directly compare the efficacy, safety and cost-effectiveness of these approaches are lacking. In the absence of such data, we do not favor a single second-line approach for all patients. Rather, we consider the pros and cons of each option with our patients and engage them in the decision-making process.

Effectiveness and immunogenicity of pneumococcal vaccination in splenectomized and functionally asplenic patients

The aim of the present study was to evaluate the effectiveness and immunogenicity of pneumococcal vaccination in 145 splenectomized and 2 functionally asplenic patients receiving the 23-valent pneumococcal polysaccharide vaccine and/or the 7-valent pneumococcal conjugate vaccine (PCV7) during the period 1996-2009. Progression of underlying malignant disease was the main cause of death in 68% of the 53 deceased patients, followed by septic shock in 13.2%. Twelve of 94 living patients developed post-vaccine complications: pneumonia in 9 patients, otitis media in 2, pneumococcal sepsis in 4. Compared with a non-splenectomized non-vaccinated control group (n=34), splenectomized patients vaccinated in the previous five years (n=15) had significantly higher GMCs (P<0.05) against serotypes 4, 6B, 9V, 14, 18C, 19F and 23F. Our data demonstrated strong serological responses in splenectomized patients within the first 5 years after pneumococcal vaccination by PCV7. Nevertheless, post-vaccine pneumococcal sepsis was still diagnosed in 3.3% of splenectomized survivors.

Short- and long-term risks of splenectomy for benign haematological disorders: should we revisit the indications?

Splenectomy has represented a key treatment option in the treatment of many benign haematological diseases, including immune thrombocytopenia (ITP) and disorders associated with ongoing haemolysis (thalassaemia major and intermedia, sickle cell disease, and hereditary or acquired haemolytic anaemias). Improvements in surgical techniques have reduced perioperative complications and mortality. Preventive measures (new protein conjugate vaccines, antibiotic prophylaxis, and increased vigilance) are thought to greatly reduce the risk of overwhelming post-splenectomy infection (OPSI), although their implementation is inconsistent. Nevertheless, there is increasing documentation of the short- and long-term risks of splenectomy, which vary according to the underlying indication. Splenectomized patients are at increased risk of venous thromboembolism, particularly within the splenoportal system. The long-term thromboembolic risk is higher in haematological disorders associated with ongoing haemolysis, particularly in thalassaemia intermedia, which has led to a more conservative approach. In comparison, patients with ITP appear to be at lower risk of adverse effects of splenectomy, which maintains its place as the potentially most curative and safe second-line treatment. However, a splenectomy-sparing approach is also emerging for ITP, and recent guidelines recommend that this procedure is deferred until ≥ 12 months from ITP diagnosis, to allow sufficient time for possible remission.

Sickle cell disease in children

Early identification of infants with sickle cell disease (SCD) by newborn screening, now universal in all 50 states in the US, has improved survival, mainly by preventing overwhelming sepsis with the early use of prophylactic penicillin. Routine transcranial Doppler screening with the institution of chronic transfusion decreases the risk of stroke from 10% to 1% in paediatric SCD patients. Hydroxyurea decreases the number and frequency of painful crises, acute chest syndromes and number of blood transfusions in children with SCD. Genetic research continues to be driven toward the prevention and ultimate cure of SCD before adulthood. This review focuses on clinical manifestations and therapeutic strategies for paediatric SCD as well as the evolving topic of gene-focused prevention and therapy.

Revised guidelines for the diagnosis and management of hairy cell leukaemia and hairy cell leukaemia variant*

The British Committee for Standards in Haematology first produced guidelines for the diagnosis and management of hairy cell leukaemia and hairy cell leukaemia variant in 2000. This revision updates those guidelines and covers the areas of diagnosis, treatment and assessment of response to therapy.

Guidelines for the diagnosis and management of hereditary spherocytosis--2011 update

Guidelines on hereditary spherocytosis (HS) published in 2004 (Bolton-Maggs et al, 2004) are here replaced to reflect changes in current opinion on the surgical management, (particularly the indications for concomitant splenectomy with cholecystectomy in children with mild HS, and concomitant cholecystectomy with splenectomy in those with asymptomatic gallstones). Further potential long term hazards of splenectomy are now recognised. Advances have been made in our understanding of the biochemistry of the red cell membrane which underpins the choice of tests. Biochemical assays of membranes proteins and genetic analysis may be indicated (rarely) to diagnose atypical cases. The diagnostic value of the eosin-5-maleimide (EMA) binding test has been validated in a number of studies with understanding of its limitations.

Asplenia and functional hyposplenism in autoimmune polyglandular syndrome type 1

Asplenia was diagnosed in four patients with autoimmune polyendocrine syndrome type-I (APS-I): two children, aged 2-4 years, from the same family and two adults, the father of the two children and his cousin. We have observed a worsening in splenic function in the children during a follow-up of a few years. Patients with APS-I should be evaluated for splenic function, since splenic dysfunction has important therapeutic implications, especially in children.