Hyposplenism in alcoholic cirrhosis, facts or artifacts? A comparative analysis with non-alcoholic cirrhosis and extrahepatic portal venous obstruction

Frequent detection of functional hyposplenism via assessment of pitted erythrocytes in patients with advanced liver cirrhosis

Background

Asplenia or functional hyposplenism are risk factors for severe infections, and vaccinations against encapsulated bacteria are advised. There are only limited data regarding the spleen function of cirrhotic patients.

Methods

We evaluated spleen function in patients with liver cirrhosis, who were prospectively enrolled in this study. Spleen function was evaluated by the measurement of pitted erythrocytes. Functional hyposplenism was defined as a percentage of PE of >15%.

Results

117 patients, mean age 58.4 years and 61.5% (n = 72) male with liver cirrhosis were included. Functional hyposplenism was diagnosed in 28/117 patients (23.9%). Pitted erythrocytes correlated with albumin (p = 0.024), bilirubin (p<0.001), international normalized ratio (INR; p = 0.004), model of end-stage liver disease (MELD) score (p<0.001) and liver stiffness (p = 0.011). Patients with functional hyposplenism had higher MELD scores (median 13 vs. 10; p = 0.021), liver stiffness (46.4 kPa vs. 26.3 kPa; p = 0.011), INR (1.3 vs. 1.2; p = 0.008) and a higher Child-Pugh stage (Child C in 32.1% vs. 11.2%; p = 0.019) as compared to patients without functional hyposplenism. Functional hyposplenism was not associated with the etiology of cirrhosis. Importantly, 9/19 patients with Child C cirrhosis had functional hyposplenism.

Conclusion

A quarter of patients with liver cirrhosis and almost 50% of patients with Child C cirrhosis have functional hyposplenism. Functional hyposplenism is associated with poor liver function and the degree of portal hypertension, which is characterized by higher liver stiffness measurements in transient elastography.

Potential role of Howell-Jolly bodies in identifying functional hyposplenism: a prospective single-institute study

Although patients with cancer and immunosuppression are at a risk of functional hyposplenism, how to detect it promptly remains unclear. Since hyposplenism allows erythrocytes with nuclear remnants (Howell-Jolly bodies [HJBs]) to appear in the peripheral blood, HJB detection by a routine microscopic examination may help identify patients with functional hyposplenism. This prospective study was thus performed to determine the underlying diseases in patients who presented with HJBs. Of 100 consecutive patients presenting with HJBs, 73 had a history of splenectomy. The remaining 27 had hematologic cancer (n = 6, 22%), non-hematologic cancer (n = 8, 30%), hepatic disorders (n = 4, 15%), premature neonates (n = 3, 11%), hemolytic anemia (n = 2, 7%), autoimmune disorders (n = 2, 7%) and miscellaneous diseases (n = 2, 7%), and their prior treatments included chemotherapy (n = 8, 30%), steroids (n = 7, 26%) and molecular-targeted therapy (n = 3, 11%). Among the 27 patients, 22 had computed tomography scans available: 3 (14%) had underlying diseases in the spleen, and the remaining 19 (86%) were all found to have a decreased splenic volume, including 11 (50%) with more than 50% of the ideal value. The present findings suggest that HJB detection identifies patients with potentially functional hyposplenism who should receive appropriate interventional treatment, such as vaccination and prophylactic antibiotics.

Capnocytophaga canimorsus: an emerging cause of sepsis, meningitis, and post-splenectomy infection after dog bites

Newly named in 1989, Capnocytophaga canimorsus is a bacterial pathogen found in the saliva of healthy dogs and cats, and is transmitted to humans principally by dog bites. This review compiled all laboratory-confirmed cases, animal sources, and virulence attributes to describe its epidemiology, clinical features, and pathogenesis. An estimated 484 patients with a median age of 55 years were reported, two-thirds of which were male. The case-fatality rate was about 26%. Its clinical presentations included severe sepsis and fatal septic shock, gangrene of the digits or extremities, high-grade bacteremia, meningitis, endocarditis, and eye infections. Predispositions were prior splenectomy in 59 patients and alcoholism in 58 patients. Dog bites before illness occurred in 60%; additionally, in 27%, there were scratches, licking, or other contact with dogs or cats. Patients with meningitis showed more advanced ages, higher male preponderance, lower mortality, and longer incubation periods after dog bites than patients with sepsis (p < 0.05). Patients with prior splenectomy presented more frequently with high-grade bacteremia than patients with intact spleens (p < 0.05). The organism possesses virulence attributes of catalase and sialidase production, gliding motility, cytotoxin production, and resistance to killing by serum complement due to its unique lipopolysaccharide. Penicillin is the drug of choice, but some practitioners prefer third-generation cephalosporins or beta-lactamase inhibitor combinations. C. canimorsus has emerged as a leading cause of sepsis, particularly post-splenectomy sepsis, and meningitis after dog bites.

Hyposplenism: A comprehensive review. Part I: Basic concepts and causes

Hyposplenism is not a rare condition and can complicate a remarkable number of illnesses. The two most time-honored diseases associated with the development of hyposplenism are sickle cell anemia and celiac disease. Hyposplenism is relatively easy to recognize by typical changes observed on the peripheral blood smear; including Howell-Jolly bodies, monocytosis, lymphocytosis, and increased platelet counts. Diagnosis can be confirmed by pitted RBC counts or 99Tc-labelled radiocolloid scan of the spleen; wherever available. Diagnosis needs to be made promptly to institute pneumococcal vaccination in a timely fashion and to recognize and treat bacterial infections promptly and aggressively because of the tendency of hyposplenic subject to develop fatal invasive disease. Overwhelming pneumococcal sepsis accounts for the major mortality cases in hyposplenic subjects; however severe infections with other encapsulated bacteria and protozoa have been reported. Hyposplenic individuals may also be at a higher risk for vascular, autoimmune and thrombotic diseases and they may have a higher risk of developing solid tumors. The commonly used pneumococcal polysaccharide vaccine is ineffective in asplenic subjects, because it requires the presence of IgM memory B cells, and should be given before splenectomy. In splenectomized, and functionally hyposplenic subjects, the pneumococcal conjugate vaccine is more effective, because it utilizes a T cell dependent mechanism, and should be the preferred vaccine in these circumstances.