Asplenism in theAsplenism in theEmergency DepartmentEmergency Department

Jim P. Getzinger, MDJim P. Getzinger, MD

William Beaumont HospitalWilliam Beaumont Hospital

Royal Oak, MIRoyal Oak, MI

Splenic Trauma in the EDSplenic Trauma in the ED

• Classification of injuryClassification of injury– Contusions Contusions – Capsular tears Capsular tears – Hematomas – subcapsular or intraparenchymal Hematomas – subcapsular or intraparenchymal – LacerationsLacerations– FractureFracture– Puncture woundsPuncture wounds– Laceration of vessels supplying hilumLaceration of vessels supplying hilum– Avulsion from vascular pedicle Avulsion from vascular pedicle

• Classification based on time Classification based on time – AcuteAcute– DelayedDelayed– OccultOccult

Injury GradeInjury Grade

• GRGR INJURY INJURY POSITION POSITION DESCRIPTION DESCRIPTION SIZESIZE• I I HematomaHematoma Subcapsular Subcapsular Nonexpanding Nonexpanding < 10%< 10%• I I Laceration Laceration Capsular tear Capsular tear NonbleedingNonbleeding < 1cm< 1cm• II II Hematoma Hematoma Subcapsular Subcapsular Nonexpanding Nonexpanding 10-50%10-50%• II II Hematoma Hematoma Intraparenchymal Intraparenchymal Nonexpanding Nonexpanding < 2 < 2

cmcm• II II Laceration Laceration Capsular tear Capsular tear BleedingBleeding

w/o Trabecular involvementw/o Trabecular involvement 1-3 cm1-3 cm• III III Hematoma Hematoma Subcapsular or Subcapsular or ExpandingExpanding

IntraparenchymalIntraparenchymal• III III Hematoma Hematoma Subcapsular Subcapsular Bleeding Bleeding > >

50%50%• III III Hematoma Hematoma Intraparenchymal Intraparenchymal > 2 > 2

cmcm• III III Laceration Laceration Parenchymal Parenchymal Involves trabecular vessels Involves trabecular vessels > 3 > 3

cmcm• IV IV Hematoma Hematoma Intraparenchymal Intraparenchymal Ruptured and BleedingRuptured and Bleeding• IV IV Laceration Laceration Involves hilar vesselsInvolves hilar vessels• V V Laceration Laceration Completely shatteredCompletely shattered• V V Laceration Laceration Hilar region Hilar region Completely devascularizedCompletely devascularized

The SpleenThe Spleen

Total splenectomy will be required in those with a hilar injury, massive subcapsular hematoma, fragmentation, or splenic avulsion.

AsplenismAsplenism

• Asplenic patients are at lifelong risk for serious Asplenic patients are at lifelong risk for serious infections, especially with encapsulated infections, especially with encapsulated organisms such as organisms such as Strep. pneumoniae, H. Strep. pneumoniae, H. influenzaeinfluenzae and and N. meningitidisN. meningitidis. .

• With the growing concern about antibiotic-With the growing concern about antibiotic-resistant pneumococci, the appropriate detection resistant pneumococci, the appropriate detection and treatment of asplenic and hyposplenic and treatment of asplenic and hyposplenic patients has become increasingly important.patients has become increasingly important.

Post-Splenectomy SepsisPost-Splenectomy Sepsis

• 1930’s – Early post-surgical studies 1930’s – Early post-surgical studies showed no increase in sepsis after showed no increase in sepsis after splenectomysplenectomy

• 1952 – King & Schumacker describe 1952 – King & Schumacker describe 5 infants post-splenectomy for 5 infants post-splenectomy for congenital spherocytosis that die of congenital spherocytosis that die of fulminant sepsis.fulminant sepsis.

Clinical FeaturesClinical Features

• Initial symptoms of overwhelming post-splenectomy Initial symptoms of overwhelming post-splenectomy infection are often mild, with an influenza-like infection are often mild, with an influenza-like presentation that includes fever, malaise, myalgias, presentation that includes fever, malaise, myalgias, headache, vomiting, diarrhea and abdominal pain. headache, vomiting, diarrhea and abdominal pain.

• Overwhelming Postsplenectomy infection (OPSI) first Overwhelming Postsplenectomy infection (OPSI) first coined by Diamond in 1969coined by Diamond in 1969– Fulminant courseFulminant course– Freq. Lack of septic focusFreq. Lack of septic focus– Bacteremia, pneumonia or meningitisBacteremia, pneumonia or meningitis– Consumptive coagulopathy, adrenal hemorrhage Consumptive coagulopathy, adrenal hemorrhage

(Waterhouse-Friderichsen syndrome) leading to shock and (Waterhouse-Friderichsen syndrome) leading to shock and coma.coma.

– Large numbers of organisms in blood (>1M/ml)Large numbers of organisms in blood (>1M/ml)

IncidenceIncidence

• ProblemsProblems– Rare event – Need large patient populationsRare event – Need large patient populations

– Infection can be years later – long f/ups req.Infection can be years later – long f/ups req.

– Incidence varies with age, underlying Incidence varies with age, underlying diseasedisease•S/P Trauma – infection 3.3 / 100 pt-yrsS/P Trauma – infection 3.3 / 100 pt-yrs

•S/P Cancer – infection 16.6 / 100 pt-yrsS/P Cancer – infection 16.6 / 100 pt-yrs

IncidenceIncidence

• O’Neal & McDonald 1981O’Neal & McDonald 1981– 256 Adult splenectomies f/u 45 mos256 Adult splenectomies f/u 45 mos– 2.7% developed sepsis2.7% developed sepsis– Estimated risk of death at Estimated risk of death at 540540 times times

normal population.normal population.

IncidenceIncidence

• Chaik and McCabe, 1985Chaik and McCabe, 1985– 776 splenectomies over mean 8.4 yrs776 splenectomies over mean 8.4 yrs– Incidence OPSI 3.7% children, 0.3% AdultIncidence OPSI 3.7% children, 0.3% Adult

• Hays et al 1986Hays et al 1986– 234 lymphoma pts, splen. Staging, f/u 234 lymphoma pts, splen. Staging, f/u

3.8 yrs3.8 yrs– 1.7% bacteremia (83% vac / 74% abx)1.7% bacteremia (83% vac / 74% abx)

IncidenceIncidence

• Ellison & Fabri, 1983Ellison & Fabri, 1983– Multistudy review of 3430 casesMultistudy review of 3430 cases– Peds 4% sepsis (1.8% mortality)Peds 4% sepsis (1.8% mortality)– Adult 1.9% sepsis (1.1% mortality)Adult 1.9% sepsis (1.1% mortality)– Est. risk – 40x for sepsis & 17x for deathEst. risk – 40x for sepsis & 17x for death– 20% cases in first 6mo, 60% in first 2 yrs20% cases in first 6mo, 60% in first 2 yrs

• Overall incidence 0.9% - 6.9%Overall incidence 0.9% - 6.9%• Mortality may exceed 50%Mortality may exceed 50%

Risk FactorsRisk Factors

• Underlying conditionUnderlying condition– Defective cellular immunityDefective cellular immunity

• Hodgkins’ disease, hypogammaglobulinemiaHodgkins’ disease, hypogammaglobulinemia– Chemotherapy, radiationChemotherapy, radiation– Bone Marrow transplantationBone Marrow transplantation

• Age GroupAge Group– Children >> AdultsChildren >> Adults– Children often have lower antibodies against Children often have lower antibodies against

encapsulated org.encapsulated org.

• Time after splenectomyTime after splenectomy– Greatest in first 2 yrs (50%-70%), but risk is lifelongGreatest in first 2 yrs (50%-70%), but risk is lifelong

Causative OrganismsCausative Organisms

• Pneumococcus - > 50%Pneumococcus - > 50%• H. influenza, Meningococcus, Strep H. influenza, Meningococcus, Strep

Pyog.Pyog.• Less commonLess common

– PseudomonasPseudomonas– Capnocytophaga canimorsus (animal bites) Capnocytophaga canimorsus (animal bites) – Malaria Malaria – BabesiosisBabesiosis– Viruses – CMV, herpes, influenzaViruses – CMV, herpes, influenza

MechanismsMechanisms

• Phagocytosis and clearance of bacteria/protozoa is Phagocytosis and clearance of bacteria/protozoa is impaired. impaired.

• Spleen is site of production of specific antibodiesSpleen is site of production of specific antibodies

• Impaired immune responseImpaired immune response– Encapsulated orgs must be opsonised before they can be Encapsulated orgs must be opsonised before they can be

phagocytosed. Production of opsonins is impaired.phagocytosed. Production of opsonins is impaired.

• Spleen controls circulating B cells capable of Spleen controls circulating B cells capable of differentiating into antipneumococcal capsular differentiating into antipneumococcal capsular polysaccharide antibody-secreting B cells. polysaccharide antibody-secreting B cells.

DetectionDetection

• Most patients with trauma will knowMost patients with trauma will know– Some older patients may not recallSome older patients may not recall

• Hiatal hernia surgery, partial gastric resection PUDHiatal hernia surgery, partial gastric resection PUD

– Careful physical examination for scarsCareful physical examination for scars– Ask about DiseasesAsk about Diseases

Medical Conditions That May Be Medical Conditions That May Be Associated with HyposplenismAssociated with Hyposplenism

CongenitalCongenital Isolated congenital Isolated congenital

anomalyanomaly Congenital cyanotic Congenital cyanotic

heart diseaseheart diseaseGastrointestinalGastrointestinal Celiac disease with or Celiac disease with or

without dermatitis without dermatitis herpetiformis*herpetiformis*

Inflammatory bowel Inflammatory bowel diseasedisease

(especially ulcerative (especially ulcerative colitis)colitis)

Whipple’s diseaseWhipple’s disease Intestinal Intestinal

lymphangiectasialymphangiectasiaLiver diseaseLiver disease Cirrhosis with or without Cirrhosis with or without

portal hypertension*portal hypertension* Chronic active hepatitisChronic active hepatitis Acute alcoholismAcute alcoholism

HematologicHematologic Sickle cell disease*Sickle cell disease* Other Other

hemoglobinopathieshemoglobinopathies (Hb S-C disease, Hb S-E(Hb S-C disease, Hb S-E disease, Hb S–b-disease, Hb S–b-

thalassemia)thalassemia) Primary thrombocythemiaPrimary thrombocythemia Fanconi’s syndromeFanconi’s syndrome Malignant histiocytosisMalignant histiocytosisAutoimmuneAutoimmune Vasculitis (may be Vasculitis (may be

associatedassociated with splenic infarct)*with splenic infarct)* Systemic lupus Systemic lupus

erythematosuserythematosus or discoid lupus*or discoid lupus* Rheumatoid arthritisRheumatoid arthritis Sjögren’s syndromeSjögren’s syndrome Graves’ diseaseGraves’ disease

InfiltrativeInfiltrative Thorium dioxide Thorium dioxide administrationadministration AmyloidosisAmyloidosis SarcoidosisSarcoidosisVascularVascular Splenic artery occlusionSplenic artery occlusion Splenic vein thrombosisSplenic vein thrombosis Celiac artery thrombosisCeliac artery thrombosisMiscellaneousMiscellaneous HIV infectionHIV infection Graft-versus-host diseaseGraft-versus-host disease Bone marrow Bone marrow transplantation*transplantation* Total parenteral nutritionTotal parenteral nutrition High-dose steroid therapyHigh-dose steroid therapy Splenic irradiation Splenic irradiation (Hodgkin’s(Hodgkin’s disease)*disease)*

Peripheral Blood SmearPeripheral Blood Smear

Management of Patients at Management of Patients at RiskRisk

• VaccinationVaccination– Give Pneumococcal, Meningococcal, and Give Pneumococcal, Meningococcal, and

Haemophilus b conjugate vaccine at Haemophilus b conjugate vaccine at least 14 days before surgery (or as soon least 14 days before surgery (or as soon as possible)as possible)

– repeat PneumoVax every 3-5 yrs repeat PneumoVax every 3-5 yrs depending on age & medical conditiondepending on age & medical condition

Pneumococcal VaccinePneumococcal Vaccine

• Developed 1983Developed 1983– 23 serotypes (approx 90%)23 serotypes (approx 90%)– Ideal conditions – fails 20-30% of Ideal conditions – fails 20-30% of

recipientsrecipients– Give before splenectomy if possibleGive before splenectomy if possible

• Immunogenicity reduced after splenectomy or Immunogenicity reduced after splenectomy or during chemo.during chemo.

– Age > 10 – revaccinate every 5 yrsAge > 10 – revaccinate every 5 yrs– Age < 10 – revaccinate every 3 yrsAge < 10 – revaccinate every 3 yrs

Antibiotics - ProphylaxisAntibiotics - Prophylaxis

• Recommended for children, especially for Recommended for children, especially for first 2 yrs after splenectomy.first 2 yrs after splenectomy.– Augmentin, Bactrim, CefuroximeAugmentin, Bactrim, Cefuroxime

• At least 5 yrs of prophylaxisAt least 5 yrs of prophylaxis• Adults – recommended standby antibioticsAdults – recommended standby antibiotics

– Taken at first sign of infectionTaken at first sign of infection– Still should seek medical attentionStill should seek medical attention

• Endemic Malaria areasEndemic Malaria areas– Mefloquine, Doxycycline or Mefloquine, Doxycycline or

chloroquine+proguanilchloroquine+proguanil

StudiesStudies

• Do NOT delay ABX therapy for labsDo NOT delay ABX therapy for labs

• LabsLabs– Hematologic profile, lytes, creatinine, Hematologic profile, lytes, creatinine,

glucoseglucose– Peripheral blood smear, buffy-coat prepPeripheral blood smear, buffy-coat prep– Blood cultures, consider CSF cxBlood cultures, consider CSF cx

• Chest XrayChest Xray

Buffy-CoatBuffy-Coat

Empiric Antibiotic TherapyEmpiric Antibiotic Therapy

• InitialInitial– Third Generation CephalosporinThird Generation Cephalosporin– With or without VancomycinWith or without Vancomycin

• Specific Treatment based on Specific Treatment based on organismorganism– Add ciprofloxacin or gentamicin if Add ciprofloxacin or gentamicin if

GI/Urine source suspectedGI/Urine source suspected– Penicillin for C. canimorsusPenicillin for C. canimorsus

IV Drug TreatmentIV Drug TreatmentDrugDrug Adult Adult

DosageDosagePediatric Pediatric

DoseDoseCefotaximeCefotaxime 2g IV q8hr2g IV q8hr 25-50mg/kg IV 25-50mg/kg IV

q6hrq6hr

CeftriaxoneCeftriaxone 2g IV q12-24hr2g IV q12-24hr 50 mg/kg IV 50 mg/kg IV q12hrq12hr

+/- Gentamicin+/- GentamicinOROR

5-7 mg/kg q24hr5-7 mg/kg q24hr 2.5mg/kg IV q8hr2.5mg/kg IV q8hr

+/- Ciprofloxacin+/- Ciprofloxacin(If GI/Urine Src susp)(If GI/Urine Src susp)

400mg IV q12hr400mg IV q12hr *do not use**do not use*

+/- Vancomycin+/- Vancomycin(when PCN (when PCN Resist)Resist)

1-1.5g IV q12hr1-1.5g IV q12hr 30mg/kg IV 30mg/kg IV q12hrq12hr

EducationEducation

• Patients should be made aware of increased risk of Patients should be made aware of increased risk of serious infection.serious infection.

• Wear MedicAlert bracelet or necklaceWear MedicAlert bracelet or necklace

• Notify their doctor immediately of any acute febrile Notify their doctor immediately of any acute febrile illness (esp. if assoc with rigors or systemic illness (esp. if assoc with rigors or systemic symptoms)symptoms)

• Seek prompt treatment even after minor dog bite or Seek prompt treatment even after minor dog bite or other animal bite.other animal bite.

In closing:In closing:

• Consider OPSI in patients with unexplained Consider OPSI in patients with unexplained hypotension, rapid onset, failed outpt abx. hypotension, rapid onset, failed outpt abx. Look for scars, history!, recent travel Look for scars, history!, recent travel (Babesia, malaria)(Babesia, malaria)

• Start ABX as soon as possible. Be aggressive!Start ABX as soon as possible. Be aggressive!– 33rdrd Gen. Cephalasporin With/Without Vanco Gen. Cephalasporin With/Without Vanco

• Don’t let GI symptoms divert diagnosisDon’t let GI symptoms divert diagnosis

Final ThoughtsFinal Thoughts

• Always check your footing/ladder carefullyAlways check your footing/ladder carefully

• Make sure someone knows you’re on the roofMake sure someone knows you’re on the roof

• If they hear a yell, and a thud, call 911.If they hear a yell, and a thud, call 911.

• When all else fails, hire someone to put up When all else fails, hire someone to put up your holiday lights!your holiday lights!