Infecção fulminante pós-esplenectomia

Splenectomy in Patients with Visceral Leishmaniasis Resistant to Conventional Therapy and Secondary Prophylaxis: A Retrospective Cohort

Some patients with visceral leishmaniasis (VL), or kala-azar, suffer relapses and low quality of life despite adequate drug therapy, especially those co-infected with HIV. Occasionally, physicians indicate splenectomy, but the benefit of the procedure needs to be analyzed systematically. Therefore, a retrospective open cohort study was conducted in Teresina, Brazil. Inpatients from a reference hospital with relapsing VL who had a rescue splenectomy between 2012 and 2019 after the nationally recommended drug therapy failed were studied. The procedure's risks and benefits were assessed in a limited-resource setting. The primary outcomes were surgical complications, complete blood count, CD4+ cell count, hospitalizations, survival time, and medical complications preceding death. Thirteen adult patients received medical and surgical indications of splenectomy (12 men and one woman). Eleven had HIV infection. Two had early and two had late complications. Four died, all of whom were infected with HIV. An additional HIV-coinfected patient, apart from the cohort, died just before surgery. The death rate after surgery was 13.3 overall and 22.1 per 100 person-years among HIV-infected patients (31% overall and 36%, respectively). The impressive rise of complete blood counts and reduction of blood transfusions and hospitalizations were observed among all patients. Also, a meaningful increase in CD4+ cells in HIV-infected patients was noted. Splenectomy may benefit patients with relapsing VL. However, before performing splenectomy, available combined drug therapy for VL should be tried.

The influence of splenic tissue on the survival and TCD4 and TCD8 lymphocyte rates in rats subjected to fecal peritonitis induction

PURPOSE

Comparing survival rates of rats subjected to spleen procedures after fecal peritonitis induction. Assessing changes in TCD4 and CD8 lymphocyte rates before and after the procedures. Correlating animal survival with CD4 and CD8 lymphocytes.

METHODS

Thirty male Wistar rats were distributed into 3 groups of ten: spleen manipulation (SM); total splenectomy (TS); subtotal splenectomy with preservation of the inferior pole (IP). Rats were subjected to surgical procedure depending on the group. Seven days after surgery they underwent induction of peritonitis and survival time was recorded. All animals were subjected to two blood collections: before surgery and 70 days after it for TCD4/TCD8 lymphocyte counting.

RESULTS

Mean survival time was longer in the IP and SM groups and shorter in the TS group; there was significant difference between them. The comparison of the median number of CD4 did not present changes, whereas the comparison of the median number of CD8 decreased in the SM and IP groups. The correlation between the median number of TCD4 and TCD8 lymphocytes and the animals' survival was not significant.

CONCLUSION

The maintenance of splenic tissue contributed to increase the survival of rats and there was a change in the number of TCD8 lymphocytes.

Recurrent kala-azar: report of two cured cases after total splenectomy

In Latin America, the causative agent of kala-azar is the intracellular protozoan Leishmania infantum. Most cases in South America are reported in Brazil. Worldwide, it mainly affects Bangladesh, Ethiopia, India, South Sudan and Sudan. Despite the high morbidity and lethality of kala-azar, most infections are asymptomatic. However, a small portion of patients evolves with recurrence of kala-azar becoming symptomatic even after all available drug treatments. Kala-azar is not a formal indication for splenectomy in adults. Splenectomy is recommended as a saving measure, when kala-azar is associated with symptomatic hypersplenism and for drug-resistant cases. In the study, we report two cases of kala-azar with splenomegaly that presented several hospitalizations due to the recurrence of the kala-azar, in addition to hospitalizations for normalizing the blood count. After splenectomy, kala-azar cases and the effects of hypersplenism are cured. Thus, splenectomy should be seen as a surgical treatment option with a curative purpose in patients with recurrent kala-azar, in whom the possibilities of drug therapy have been exhausted and even so they progressed with hypersplenism and clinical repercussions.

Effects of inferior splenic lobe pole fixation and gastrosplenic peritoneal membrane section on the vitality of the remanent of subtotal splenectomy in rats

PURPOSE

To investigate the vitality of the spleen lower pole after subtotal splenectomy with suture to the stomach and after posterior peritoneal gastro-splenic membrane section, using macro and microscopic evaluations.

METHODS

Sixty Wistar rats were used in this study and were randomly distributed in the three groups: Group 1: (n=20), subtotal splenectomy with lower pole preservation, Group 2: (n=20) subtotal splenectomy with lower pole preservation and suture to the stomach, Group 3: subtotal splenectomy with lower pole preservation and posterior peritoneal gastrosplenic ligament section. The animals were sacrificed 45 days after the surgery and the spleen lower poles were removed for macroscopic and microscopic examination.

RESULTS

All animals in this series survived. No macroscopic differences were encountered between the groups. Microscopic evaluation observed statistic difference concerning fibrosis between group 1 and 3 (p ≤ 0.05), but the analysis for necrosis and inflammation presented no differences.

CONCLUSION

Vitality of the spleen lower pole after subtotal splenectomy is minimally modified when it is fixed to the stomach or when the posterior peritoneal gastrosplenic ligament is resected.

Experimental splenectomies and malaria in mice

PURPOSE

To evaluate the importance of spleen in malaric infection in murino model, comparing the parasitemia and the titles of immunoglobulins in the different groups.

METHODS

It was used female mice non-isogenic, inoculated with Plasmodium berghei, cepa ANKA, intraperitoneally. The parasitemia was analyzed in 23rd, 25th, 27th and 32nd day of the experiment, being the stained blood exam colored by Giemsa. The titles of the total serum immunoglobulins IgM and IgG were analyzed by Dot-ELISA technique, at 6th, 22nd and 32nd day, when the animals were sacrificed.

RESULTS

The parasitemia was gradual in all the inoculated groups. In the end of the experiment, the animals with partial parasitemia present superior parasitemia, but next to the non-splenectomized, while the asplenics present difference bigger than the double. The levels of total serum IgM and IgG didn't have significant changes with the removal partial or total splenic.

CONCLUSION

The techniques conservatives in splenic trauma are possible and necessary. The importance of remaining spleen in the clearance of red blood cells parasitized by Plasmodium berghei showed being efficient, in order to avoid serious complications resulting of the malaria in mice.

Splenectomy does not interfere with immune response to Leishmania major infection in mice

Spleen is one of the largest lymphoid organs in the body; it harbors immune cells including antigen presenting cells, B and T lymphocytes. It has an important role in humoral and cellular immune responses. Herein we investigated the role of spleen in the immune response to experimental Leishmania major infection. It is known that C57BL/6 mice are resistant to L. major infection whereas BALB/c mice are susceptible. Although splenectomy was associated with reduced serum levels of IFN-gamma, absence of the spleen did not change the profile of L. major infection in the resistant C57BL/6 and BALB/c susceptible mice. Both strains of mice maintained the same profile of cytokine production in regional lymph nodes after splenectomy and responded in the same way against the infection. Only splenectomized BALB/c mice had a reduction in IL-4 and IL-10 production by lymph node cells early in infection. Our data suggest that, in localized infections, regional lymph nodes may replace efficiently the immunological role of spleen in the cellular and humoral immune responses.