Northern region asplenia register--analysis of first two years

Asplenia and spleen hypofunction

Asplenia (the congenital or acquired absence of the spleen) and hyposplenism (defective spleen function) are common causes of morbidity and mortality. The spleen is a secondary lymphoid organ that is responsible for the regulation of immune responses and blood filtration. Hence, asplenia or hyposplenism increases susceptibility to severe and invasive infections, especially those sustained by encapsulated bacteria (namely, Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type b). Asplenia is predominantly due to splenectomy for either traumatic events or oncohaematological conditions. Hyposplenism can be caused by several conditions, including haematological, infectious, autoimmune and gastrointestinal disorders. Anatomical disruption of the spleen and depletion of immune cells, especially IgM memory B cells, seem to be predominantly responsible for the clinical manifestations. Early recognition of hyposplenism and proper management of asplenia are warranted to prevent overwhelming post-splenectomy infections through vaccination and antibiotic prophylaxis. Although recommendations are available, the implementation of vaccination strategies, including more effective and immunogenic vaccines, is needed. Additionally, screening programmes for early detection of hyposplenism in high-risk patients and improvement of patient education are warranted.

Audit of Post-Splenectomy Prophylaxis in a Single Tertiary Center in Slovenia: Where Are We and What Should Be Done?

Background: Patients who have had splenectomies are at increased risk for severe infections and overwhelming sepsis caused by pneumococci, meningococci, Haemophilus influenzae, and other encapsulated pathogens. Prophylactic measures are important to reduce mortality in this group; among them are vaccinations, antibiotic prophylaxis, and education. We performed a retrospective audit of post-splenectomy prophylactic measures, focusing on vaccinations and antibiotic prophylaxis coverage. Patients and Methods: We included 156 adult patients who had splenectomies between January 2010 and December 2018 in a study conducted at a single tertiary medical center. Data regarding vaccinations, antibiotic prophylaxis, and severe infections in the post-splenectomy period were obtained from medical records and supplemented by a patient-devised questionnaire. Results: Overall 121 of 156 (77.5%) of patients received a basic pneumococcal vaccination, although only 27 of 70 (38.6%) received re-vaccination after five years. Lower vaccination coverage was observed for meningococcal diseases and Haemophilus influenzae type b (Hib) disease with 57.0% (89/156) and 55.7% (87/156) vaccination coverage, respectively. A difference in pneumococcal vaccination coverage between patients after elective splenectomy (81/91; 89.0%) and non-elective splenectomy (40/65; 61.5%) was observed. However, no difference was observed among meningococcal and Hib vaccination coverage. Antibiotic prophylaxis was recommended to patients more frequently after elective splenectomy (41/82; 50.0%) than non-elective (16/56; 28.6%) yet after an elective splenectomy, patients discontinued the prophylaxis more often than those after a non-elective surgery. Overall, only 30 of 146 (20.5%) of patients received antibiotic prophylaxis over two years. In the observed period, 12.3% of patients suffered a severe infection. Conclusion: Our study shows that there is adequate basic pneumococcal vaccination coverage among patients after a splenectomy particularly after an elective splenectomy, but there is a lack of and an inadequate implementation of other prophylactic measures. There is an urgent need for an organized approach involving better education of healthcare practitioners as well as patients concerning the risk of asplenia. In addition, an improved long-term follow-up is needed including establishing a central registry for the asplenic patients in Slovenia.

Post-splenectomy sepsis: preventative strategies, challenges, and solutions

Removal of the spleen had already been established as a routine technique to treat splenic trauma and other diseases affecting the spleen before the anatomy, physiology, and function of the spleen were known in the mid-twentieth century. It is now widely accepted that the splenectomized individual is at increased risk for infection, in particular, overwhelming post-splenectomy infection (OPSI). OPSI is a syndrome of fulminant sepsis occurring in splenectomized (asplenic) or hyposplenic individuals that is associated with high mortality and morbidity. Poorly opsonized bacteria such as encapsulated bacteria, in particular, Streptococcus pneumoniae, are often implicated in sepsis. The spleen is a reticuloendothelial organ that facilitates opsonization and phagocytosis of pathogens, in addition to cellular maintenance. Splenectomy is associated with an impairment in immunoglobulin production, antibody-mediated clearance, and phagocytosis, leading to an increased risk of infection and sepsis. Early identification of the at-risk patient, early blood cultures prior to antibiotic administration, urgent blood smears and fast pathogen-detection tests, and sepsis bundles should be utilized in these patients. Prompt management and aggressive treatment can alter the course of disease in the at-risk splenectomized patient. Overwhelming post-splenectomy infection can be prevented through vaccination, chemoprophylaxis, and patient education. This article evaluates post-splenectomy sepsis by summarizing the anatomy and function of the spleen, physiological changes after splenectomy that predispose the splenectomized patient to infection, and current management and prevention strategies.

Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy)

Patients with anatomic or functional asplenia have a 10-50 times higher risk than general population to develop Overwhelming Post-Splenectomy Infection. Evidences are unanimous in recommending splenectomised patients to receive meningococcal, antipneumococcal and Haemophilus influenzae type B vaccinations according to a specific timing. In Italy there are no current data on the immunisation coverage in these patients. This study aims to investigate immunisation coverage in patients undergoing elective or urgent splenectomy for 2012-2013 in the 3 Apulian hospitals. The patients discharged with the code ICD-9-CM 41.5 - "Total splenectomy" were enrolled. The administration of vaccines was verified through consultation of medical records, archives of general practitioners and vaccination offices. In the study period, 166 subjects underwent splenectomy and none of them received vaccinations during hospitalization. 25 splenectomised patients (15.1%) received at least one of the recommended vaccinations. 21 patients (12.6%) received vaccine against Streptococcus pneumonia, 13 (7.8%) meningococcal vaccine, 10 patients (6%) Haemophilus influenzae type B vaccine. The low vaccination coverage could be due both to poor perception of the risk of infection and to a lack of knowledge on vaccinations by surgeons. For this reason it is necessary to draw up and share operational protocols that establish the administration of vaccines.

Healthcare provider knowledge, attitudes and practices in patients on the Victorian Spleen Registry

OBJECTIVE

This study aimed to evaluate the knowledge, attitudes and practices of healthcare providers regarding asplenic patients and to assess their satisfaction with the Victorian Spleen Registry (VSR) service.

METHODS

Survey forms were sent to 992 healthcare providers listed as caring for at least one patient registered on the VSR.

RESULTS

A total of 223 completed questionnaires were returned. Healthcare providers heard about the VSR mainly from another healthcare professional or through a healthcare institution (31.7%), via online or printed resources (30.8%) or from their patients (24.4%). Most respondents valued the work of the VSR in providing information to healthcare professionals (71.4%), providing a reminder service for vaccinations (66.7%) and providing education to patients (60.5%). Most of those surveyed correctly identified high-risk infections for asplenic and hyposplenic patients with encapsulated organisms, but less than one-third identified a risk with malarial infections (32.9%). Providers always recommended influenza vaccinations, emergency standby antibiotics and an alert medallion or card in 92.8%, 63.6% and 36.4% of cases, respectively.

CONCLUSIONS

Healthcare providers value and are satisfied with the service provided by the VSR. Patients can play a valuable role in communicating with their health providers. This survey may have been of value to healthcare providers by heightening awareness of the VSR website as well as knowledge of the registry.

IMPLICATIONS

The results positively reflect the functioning of the VSR, although better promotion of the VSR among healthcare professionals and consideration of expansion is needed.

Vaccination considerations in the asplenic patient

Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.

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

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology (BCSH) in 1996 and formally reviewed in 2002. Although the guidelines originated from discussion within the BCSH, the intended readership is wide given the multidisciplinary nature of the management of hyposplenism.

Adherence to preventive measures after splenectomy in the hospital setting and in the community

Overwhelming post-splenectomy infection (OPSI) remains a long-term risk in asplenic patients, which may be reduced by appropriate preventive measures. Specific guidelines have been developed to lower its incidence.

AIMS

To assess the implementation of guidelines by specialized physicians of a university hospital and primary care physicians.

METHODS

A retrospective review of splenectomized patients' medical files over a six year period was carried out. Patients' general practitioners were contacted and a questionnaire was sent to them.

RESULTS

154 individuals who underwent splenectomy between 2000 and 2005 were eligible (62 children and 92 adults): 70.8% received pneumococcal vaccine, 44% received vaccine against Haemophilus influenzae type b with a good cover of children population (88.7%), 24% received meningococcal vaccine. Prophylactic antibiotics were prescribed in 74% of patients. Septic events were found in 8.4%, and global mortality was 11.7% during a mean follow-up period of 4.5 years.

CONCLUSIONS

Management of the infectious risk in asplenic patient has to be improved: some of the patients are not correctly identified as at risk of OPSI, and vaccination against Neisseria meningitidis is insufficient. Hospital specialists should improve the implementation of guidelines and give better information to general practitioners involved.

Cost-effectiveness of a post-splenectomy registry for prevention of sepsis in the asplenic

BACKGROUND

Overwhelming, sometimes fatal infections represent a lifelong risk after surgical removal of the spleen, or in patients who develop hyposplenism as a consequence of illnesses. This risk may be reduced by all or a combination of vaccination, antibiotic prophylaxis and education. We aimed to determine if a registry approach to delivering these interventions would be cost effective using our own experience and published data.

METHOD

The decision model compared a cohort of 1,000 people covered by a registry to a cohort of 1,000 people with no registry. The impact of the registry was assessed in terms of achieved rates of vaccination, chemoprophylaxis and education, consequent outcomes of overwhelming post-splenectomy infection (OPSI) and mortality (years of life lived). The cost-effectiveness of the registry compared with no registry was estimated in terms of additional cost per case of OPSI avoided and as additional cost per life year gained.

RESULTS

In the first two years, the additional cost of the registry was dollar 152,611 per case of OPSI avoided or dollar 205,931 per life year gained. After this initial registration period the cost-effectiveness improves over time, such that over the cohort lifetime a post-splenectomy register is associated with an additional cost of dollar 105,159 per case of OPSI avoided or dollar 16,113 per life year gained.

CONCLUSION

A registry-based approach is likely to prove cost effective in terms of mortality and rates of OPSI avoided.

ADHERENCE TO GUIDELINES FOR PREVENTION OF POSTSPLENECTOMY SEPSIS. AGE AND SEX ARE RISK FACTORS: A FIVE-YEAR RETROSPECTIVE REVIEW

BACKGROUND

Vaccination, education and use of long-term antibiotics are recommended in expert guidelines for the prevention of infectious complications after splenectomy. However, studies outside Australia have shown poor adherence to the guidelines.

METHOD

The aim of this study was to determine overall adherence to the guidelines and to ascertain any independent risk factors for poor compliance with the guidelines. A retrospective review of hospital records between 1999 and 2004 was carried out.

RESULTS

Indications for splenectomy of the 111 patients in this review included post-trauma (32), haematological (32), cancer surgery (24), iatrogenic (12) and others (11). On multivariable analysis, age was associated with a 28% less likelihood to receive education (odds ratio (OR) 0.72; 95% confidence interval (CI) 0.56-0.92; P = 0.009) and 36% less likelihood to receive long-term antibiotics (OR 0.64; 95% CI 0.52-0.80; P < or = 0.001). Women were four times more likely to receive education (OR 4.03; 95% CI 1.16-14.0; P = 0.028) and patients who had undergone splenectomy in 2004 were 22 times more likely to have received education compared with those in 1999 (OR 22.53; 95% CI 3.12-162.34; P = 0.002).

CONCLUSION

Education for prevention of sepsis after splenectomy is poorly documented and may be incomplete. Older age and male sex are risk factors in non-adherence to guidelines for prevention of postsplenectomy sepsis. Strategies such as alert cards and information brochures may improve adherence to guidelines particularly in older patients.

Near-total splenectomy for hereditary spherocytosis: clinical prospects in relation to disease severity

We prospectively studied the efficacy of near total splenectomy (NTS) for managing hereditary spherocytosis (HS) based on haemoglobin (Hb), total bilirubin and splenic remnant regrowth in 30 children receiving NTS for HS between November 1996 and December 2004 (mean followup 3.6 years). Patients were classified into three severity groups. At followup, mean Hb had increased by 2.9-5.0 g/dl (P = 0.110) and bilirubin dropped by 15.4-56.4 mumol/l. Remnant regrowth was moderate, within the weight-specific norm. Amongst spleen-preserving techniques, NTS shows markedly lower rates of recurrent haemolysis, remnant regrowth and secondary operations, thus potentially benefiting all clinical forms of HS.

Vaccination coverage in adults undergoing splenectomy: evaluation of hospital vaccination policies

Vaccination coverage in 595 adult patients undergoing total splenectomy in the Hospital Clinic of Barcelona during 1992-2002 was studied. The rates of cover for pneumococcal, Haemophilus influenzae type b and meningococcal vaccines were 63, 63 and 61% respectively, during 2000-2002; 32, 17 and 22% in 1997-1999; and 24, 9 and 8% in 1992-1996. Multivariate analysis showed a greater risk of no vaccination in splenectomies due to trauma, malignant neoplasms of solid organs and incidental splenectomy compared with both neoplastic and non-neoplastic haematological disease, and those patients undergoing splenectomy before 2001. Coverage (>/=1 vaccine) since 1997 in patients with haematological diseases was 83.5% (71/85), haematological neoplasias 69.2% (18/26), solid organ neoplasms 38.3% (36/94), incidental splenectomy 35.6% (16/45), and traumas 28.4% (21/74). Mandatory hospital admission of patients undergoing splenectomy offers a good opportunity for vaccination of these patients. Specific vaccination policies should be developed to take advantage of this circumstance.

Pneumococcal vaccination in splenectomised cancer patients

Although pneumococcal vaccination has been recommended in splenectomised patients for more than 30 years, its use remains unsatisfactory. We conducted two consecutive retrospective assessments to determine the rate of pneumococcal vaccination among splenectomised cancer patients at a single institution. We found that 75% (82 of 115) of splenectomised cancer patients had received at least one documented pneumococcal vaccination as compared to only 59.7% of patients identified in a previous assessment conducted 1997. 20% (22 of 115) of the patients had not been vaccinated at all. Splenectomy was performed in 54% because of Hodgkin lymphoma. The pneumococcal vaccination coverage in this subgroup has risen from 40% in the previous assessment (1997) to 93% in the current survey. In conclusion, patients splenectomised at a young age because of Hodgkin lymphoma are the key group at risk for insufficient pneumococcal vaccination. Repeated assessments of the pneumococcal vaccination status increased the rate of vaccination.

The absent and vanishing spleen: congenital asplenia and hyposplenism--two case reports

Two unrelated patients are reported: one with isolated familial asplenia diagnosed postmortem, the other with isolated hyposplenism diagnosed after recurring invasive bacterial infections. Because both children died of fulminant septic shock, the importance of early diagnosis of splenic dysfunction is evident. Clues for an early diagnosis of congenital asplenia are recurrent invasive bacterial infections, Howell-Jolly bodies in the blood smear or a relative with congenital isolated asplenia. Although the guidelines for infection prevention in asplenism--patient education, antibiotic prophylaxis and vaccination--are well defined, controversy remains as to how to differentiate hyposplenism from functional asplenism.

CONCLUSION

Based on the present observations, we define a patient as functionally asplenic--and therefore at risk for life-threatening infections-when Howell-Jolly bodies are present in the blood smear, a very small spleen is found by ultrasound, or splenic blood flow is compromised.

Guidelines for the diagnosis and management of hereditary spherocytosis

Hereditary spherocytosis (HS) is a heterogeneous group of disorders with regard to clinical severity, protein defects and mode of inheritance. It is relatively common in Caucasian populations; most affected individuals have mild or only moderate haemolysis. There is usually a family history, and a typical clinical and laboratory picture so that the diagnosis is often easily made without additional laboratory tests. Atypical cases may require measurement of erythrocyte membrane proteins to clarify the nature of the membrane disorder and in the absence of a family history, occasionally molecular genetic analysis will help to determine whether inheritance is recessive or non-dominant. It is particularly important to rule out stomatocytosis where splenectomy is contraindicated because of the thrombotic risk. Mild HS can be managed without folate supplements and does not require splenectomy. Moderately and severely affected individuals are likely to benefit from splenectomy, which should be performed after the age of 6 years and with appropriate counselling about the infection risk. In all cases careful dialogue between doctor, patient and the family is essential. Laparoscopic surgery, when performed by experienced surgeons, can result in a shorter hospital stay and less pain.

Management of patients undergoing splenectomy in an Irish teaching hospital: impact of guidelines

INTRODUCTION

Overwhelming post-splenectomy infection (OPSI) has a 50-70% mortality rate and carries a lifetime risk for the asplenic patient. Specific British guidelines have been developed to reduce its incidence.

AIMS

To determine whether British guidelines were being followed in our own institution and what impact they had on overwhelming post-splenectomy infection.

METHODS

Retrospective chart review of 100 splenectomies performed by Department of Surgery, Beaumont Hospital from January 1990 to January 2000.

RESULTS

Twenty per cent of patients were discharged without any recommended vaccinations. Prophylactic antibiotics were not prescribed in 53% of patients. Just 12% of charts document a verbal explanation of the complications and management of asplenia to the patient. Overall septic mortality was 12%, of whom 8% died in hospital and 4% after discharge.

CONCLUSION

Management of the asplenic patient has improved but is far from complete. A central register of asplenic patients and national asplenic guidelines should be established in Ireland to ensure optimum patient care.

Clinically significant newly presenting autoimmune thrombocytopenic purpura in adults: a prospective study of a population-based cohort of 245 patients

The true incidence and prognosis of autoimmune thrombocytopenic purpura (ITP) in adults is unknown. We present the results of a prospective study in a population-based cohort of newly presenting adults (> or = 16 years) with ITP and platelet count of < 50 x 109/l, which took place between 1 January 1993 and 31 December 1999 in the former Northern Health Region in the UK (population 3.08 million). A total of 245 cases were confirmed by bone marrow examination with a median follow-up of 60 months (range 6-78 months). There were 134 females/111 males (1.2:1). Overall incidence was 1.6 per 105 per annum. Absolute incidence was similar for both sexes, with highest age-specific incidence in those aged > 60 years. Thirty patients (12%) presented with frank bleeding, and 28% were asymptomatic. Forty-five patients (18%) received no treatment, and 135 (55%) received first-line treatment only. Thirty patients (12%) underwent splenectomy. There were four deaths (1.6%) from bleeding and/or the complications of therapy in this cohort, but only one was in the acute phase of the illness. The majority of patients (155 out of 245) achieved remission (platelet count > 100 x 109/l), with a further 59 (24%) in partial remission with no symptoms (platelet count 30-100 x 109/l). This population-based study suggests that the traditional view of adult ITP as being a predominantly chronic disease that preferentially affects females needs to be modified.

The immunopathogenesis of meningococcal disease

This review describes the mechanisms of the immune response to meningococcal disease, examining the extent to which individual variation of the immune response can determine susceptibility. It concludes by summarising the difficulties encountered by recent efforts to develop new immunomodulatory treatments.

Prevention and management of infections in patients without a spleen

Patients who lack a functioning spleen become vulnerable to sepsis caused by bacteria and, occasionally, protozoa. The risk is higher in children and in those who have had immunosuppressive treatment, and the risk remains lifelong. Overwhelming post-splenectomy infection (OPSI) occurs at an estimated incidence of 0.23-0.42% per year, with a lifetime risk of 5%. Episodes of OPSI are emergencies, requiring immediate parental antibiotics and intensive care; intravenous immunoglobulins may be useful. OPSI carries a mortality of 38-69%. Streptococcus pneumoniae is the commonest infecting organism, accounting for 50-90% of isolates from blood cultures in reported series; it is particularly common in children with sickle cell disease. Less commonly, the infecting organisms are other bacteria, Babesia or Ehrlichia. OPSI may be, to some extent, preventable by several interventions. These are surgical conservation of the spleen; immunization against S. pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis; prophylactic antibiotics; stand-by antibiotics; patient information sheets; and a medical alert bracelet. Asplenic patients living in malaria-endemic areas require optimal prophylaxis. The initial step in prevention of OPSI is the creation of an asplenia register, as many patients are not covered by these simple measures.

Pneumococcal conjugate vaccines overcome splenic dependency of antibody response to pneumococcal polysaccharides

Protection against infections with Streptococcus pneumoniae depends on the presence of antibodies against capsular polysaccharides that facilitate phagocytosis. Asplenic patients are at increased risk for pneumococcal infections, since both phagocytosis and the initiation of the antibody response to polysaccharides take place in the spleen. Therefore, vaccination with pneumococcal polysaccharide vaccines is recommended prior to splenectomy, which, as in the case of trauma, is not always feasible. We show that in rats, vaccination with a pneumococcal conjugate vaccine can induce good antibody responses even after splenectomy, particularly after a second dose. The spleen remains necessary for a fast, primary response to (blood-borne) polysaccharides, even when they are presented in a conjugated form. Coadministration of a conjugate vaccine with additional nonconjugated polysaccharides of other serotypes did not improve the response to the nonconjugated polysaccharides. We conclude that pneumococcal conjugate vaccines can be of value in protecting asplenic or hyposplenic patients against pneumococcal infections.

Overwhelming infection in asplenic patients: current best practice preventive measures are not being followed

AIMS

Patients without spleens are at increased risk of overwhelming infection. Recently, greater efforts, including the publication of national guidelines, have been made to improve the management of asplenic individuals. In theory, risks of serious sepsis can be reduced by good advice, immunisation, and antibiotic prophylaxis. In practice, such preventive measures might not be followed or may fail. A study of recent cases of overwhelming postsplenectomy infection (OPSI) was undertaken to examine specific associated factors and to determine whether currently recommended preventive measures are being followed.

METHODS

Cases of OPSI were identified and reported mainly by microbiologists across the country using a specifically designed proforma. Data including the nature of the infection and vaccination/ antibiotic prophylaxis history since splenectomy were obtained.

RESULTS

Seventy seven cases were reported. The age range varied from 3 months (congenital asplenia) to 87 years. In those who had undergone surgical splenectomy, the time interval between surgery and OPSI varied from 24 days to 65 years. Overall mortality reached 50%, with underlying haematological malignancy associated with the highest death rate. Streptococcus pneumoniae caused approximately 90% episodes. Only 31% individuals had received pneumococcal vaccination before OPSI. Seven of 17 pneumococcal infections in immunised cases could be considered vaccine failures. Few patients had been adequately advised on antibiotic prophylaxis or other measures.

CONCLUSIONS

Currently accepted best practice for managing asplenic patients is not being followed. Some OPSI cases may still be preventable but many asplenic individuals remain unrecognised. The compilation of asplenic patient registers might help to implement agreed policies with audit necessary to evaluate compliance. More is needed to ensure optimal management for this cohort of the population.

Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited

Absence of the spleen or splenic function predisposes individuals to risk of overwhelming infection. These infections are most often due to encapsulated organisms, especially pneumococcus, Haemophilus influenzae type b, and meningococcus, but any bacterial agent may cause the rapid onset of septicemia, meningitis, pneumonia, and shock characteristic of the asplenic-hyposplenic condition. The risk is greatest in infants and young children, but asplenic-hyposplenic adults also have an increased risk of infection. Prophylactic antibiotics and immunization with polyvalent pneumococcal, H. influenzae type b, and meningococcal vaccines have reduced the incidence of infections in asplenic-hyposplenic individuals, but even these measures have not eliminated the risk. Surgeons have adopted techniques to save as much splenic tissue as possible and some splenic functions, such as pitting red cells, have been preserved, but conservative surgery has not provided total protection against overwhelming infection. Therapies designed to interrupt the cascade of overwhelming sepsis have not yet been successful. In those cases in which the spleen is surgically removed, the underlying disease or condition leading to splenectomy influences the risk of sepsis. Splenectomy incidental to other operations, such as gastrectomy, results in the lowest risk for overwhelming infection, but this is still some 35-fold greater than the risk for overwhelming infections in the general population. In increasing order of risk, the other main indications for surgical removal of the spleen are idiopathic thrombocytopenia purpura, trauma, transplantation procedures, hereditary spherocytosis, staging Hodgkin's disease, portal hypertension with hypersplenism, and thalassemia. Pathologists should comment on the risk of overwhelming sepsis when spleens are processed as surgical specimens, and should carefully weigh all splenic tissue, including accessory spleens and splenic implants (splenosis), in autopsy cases with and without overwhelming sepsis.

The diagnosis and management of hereditary spherocytosis

Hereditary spherocytosis (HS) is relatively common in Caucasian populations; most individuals have mild or only moderate disease. There is commonly a family history and a typical clinical and laboratory picture so that the diagnosis is usually easily made without additional laboratory tests. Atypical cases may require measurement of membrane proteins and molecular genetics to clarify the nature of the membrane disorder. It is particularly important to rule out stomatocytosis because splenectomy is contraindicated because of the thrombotic risk. Mild HS can be managed without folate supplements and does not require splenectomy. Moderately and severely affected individuals are likely to benefit from splenectomy, which should be performed after the age of 6 and with appropriate counselling about the risk of infection. In all cases careful dialogue between physician, child and the family is essential. Laparoscopic surgery can result in shorter hospital stay and less pain.