Written by: Will LaPlant, MD (EM Resident Physician, PGY-1, NUEM); Edited by: Andrew Moore, MD (EM Resident Physician, PGY-3, NUEM); Expert Commentary by: Brian Wolf, MD
Introduction
Deep into a fast track shift filled with sprained ankles and finger pain, I was excited to see what I thought was my first case of quadriceps rupture: a late 30s male whose leg gave out shortly after a strenuous leg workout, associated with audible “pop” and significant pain with hip flexion. As I headed out of the exam room, however, the patient added a key detail. “Well, I’ve also been having these drenching night sweats since the leg pain started. I normally take my temperature since I had my spleen removed a few years ago, but I’m just in town for business…”
Mourning the death of my neat and tidy differential diagnosis, I snuck off to find a computer before presenting my case. Just how much did this additional history matter?
Splenectomy vs. Hyposplenism
Asplenia can be either surgical or functional. There are numerous indications for partial (preferred) or full splenectomy including severe trauma, cancer, or hematological conditions such as thalassemia. Notably, even partial splenectomy confers a significant degree of hyposplenism. Functional asplenia is classically thought of in those with sickle cell disease, where splenic engorgement and autoinfarction lead to progressive hyposplenism starting early in infancy ; however, numerous other conditions can cause a hyposplenic state, including bone marrow transplant (40% with hyposplenism), celiac disease (33-76%), HIV/AIDS (36%), hepatic cirrhosis/portal hypertension (37-100%), and SLE (7%) [1]. Given the impressive prevalence of hyposplenism in these conditions and the inability to assess splenic function in the emergency department (ED), the worst should be assumed, especially in a toxic appearing patient.
The Problem: Overwhelming Post-Splenectomy Infection (OPSI)
Patients with asplenia are at significant risk for fulminant sepsis from encapsulated organisms: S. pneumoniae (most common), H. influenzae, and N. meningitides. The risk for infection decreases over time since splenectomy, but persists throughout the patient’s life [2]. Mortality is high (up to 70%), butis markedly reduced by early intervention (10-40%) [3]. Clinical presentation can be mild with vague flu-like symptoms, and a localizing source such as pneumonia or meningitis may not always present [4]. The clinician must be alert for rapid deterioration and DIC, a common complication, must be considered in all patients with asplenia.
Other Problems
Due both to the conditions that predispose patients to asplenia as well as asplenia itself, these patients may be at higher risk for VTE events and pulmonary hypertension with right heart failure, although this data is quite limited and evolving [5].
Key Elements of the History
- Are you up to date on your vaccines, including vaccines for your spleen? (PCV13 + PPSV23, HIB, Meningococcal, influenza)
- Have you ever been hospitalized for a blood infection? (markedly increased risk of sepsis)
- When was your last dose of NSAID/Acetaminophen? (IE, can we trust your temperature in the ED)
- Any recent dog or cat bites? (high risk for sepsis from C. canimorsus and requires prophylactic antibiotics [4])
Review of Systems
Skin Manifestations of DIC [http://healthfixit.com/petechiae-petechia-pictures-causes-diagnosis-treatment/]
Night sweats + rash are especially important to ask about in addition to your standard ROS. Pulmonary (pneumonia) and neuro symptoms (meningitis) should be addressed.
Physical Exam: Remember to check for signs of DIC (petechiae/purpural rash, bleeding)
Labs: CBC, CMP, Blood Cultures x2, UA, DIC Panel (if suspicious)
Imaging: CXR
Antibiotic Choice: Vancomycin (15 mg/kg) + Ceftriaxone (2g)
Disposition: Obs vs. Admit. vs. ICU (sorry, you’re not going home)
The Case: Wrap Up
Based on the patient’s night sweats and thigh pain, labs including blood cultures were drawn, antibiotics started, and the patient was admitted for observation. CT scan in the ED was deferred for inpatient MRI, which showed multiple small abscesses in the musculature of the thigh. On further pressing by the infectious disease physician, the patient admitted to recent steroid use by injection into his thigh, serving as a nidus for infection.
Pearls
There is a higher prevalence of functional asplenia than you might think (patients with stem cell transplant, cirrhosis, HIV, or celiac disease)
Have a low threshold to give IV antibiotics and observe a hyposplenic patient with reported history of fever
Consider asking about steroids when you ask about other drug use
Expert Commentary
Nice job reviewing the complications in patient with functional/anatomical asplenia. I really enjoyed how you used a case as a guide for your discussion. From an infectious perspective, asplenia poses a serious risk factor in acquiring various types of infections. The spleen plays a critical role for the immune system in having a robust response to various encapsulated organisms. Encapsulated organisms contain a polysaccharide “shell” which serves at the prime region to trigger the immune system. These polysaccharides serve as the antigens to trigger both the adaptive and innate immune system responses, which occur for these organisms within the spleen. Without a function/anatomical spleen, both immediate and memory immune responses to these organisms is impaired, leading to a delay in organism clearance and risk for disseminated infection [7].
As more patients with functional/anatomical asplenia are being vaccinated, different bacteria have begun causing infections compared to pre-vaccination years. Current guidelines recommend empiric therapy for asplenic patients presenting to the ED for fevers, with Ceftriaxone +/- Vancomycin. Two studies have evaluated infecting organisms and the types of infections in patients who had undergone splenectomy [8,9]. Interestingly while Streptococcus pneumoniae remained a common cause of infection, Enterobacteriaceae (typical gram negative bacteria) were the most common cause of infections. Patients who present with staphylococcal infections, 7 out of 8 cases were associated with skin and soft tissue infections, while the last was due to bacteremia. In light of how common Staphylococcus aureus is as an infecting organism, it is reasonable to consider adding Vancomycin to Ceftriaxone for patients with functional/anatomical asplenia presenting to the ED with fevers if there is a concern for skin or soft tissue infections.
Brian Wolf, MD
Fellow, Division of Infectious Disease; Department of Medicine; Northwestern University, Feinberg School of Medicine
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How to cite this blog post
[Peer-Reviewed, Web Publication] LaPlant W, Moore A (2017, March 14). Asplenia In The ED [NUEM Blog. Expert Commentary By Wolf B]. Retrieved from http://www.nuemblog.com/blog/asplenia-in-the-ed
References
- Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet. 2011;378(9785):86-97. doi:10.1016/S0140-6736(10)61493-6.
- Thomsen RW, Schoonen WM. Annals of Internal Medicine Risk for Hospital Contact With Infection in Patients With Splenectomy. Ann Intern Med. 2009;(151):546-555.
- Morgan TL, Tomich EB. Overwhelming post-splenectomy infection (OPSI): A case report and review of the literature. J Emerg Med. 2012;43(4):758-763. doi:10.1016/j.jemermed.2011.10.029.
- Solomon CG, Rubin LG, Schaffner W. Care of the Asplenic Patient. N Engl J Med. 2014;371:349-356. doi:10.1056/NEJMcp1314291.
- O’Neal Jr. HR, Niven AS, Karam GH. Critical Illness in Patients with Asplenia. Chest. 2016. doi:10.1016/j.chest.2016.03.044.
- William BM, Thawani N, Sae-Tia S, Corazza GR. Hyposplenism: A comprehensive review. Part II: Clinical manifestations, diagnosis, and management. Hematology. 2007;12(2):89-98. doi:10.1080/10245330600938463.
- Gilsdorf, Janet R. "316." Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Updated Edition,. 8th ed. Philadelphia: Saunders, 2015. 3466-474.
- Sakran, W. "Clinical Spectrum of Serious Bacterial Infections among Splenectomized Patients with Hemoglobinopathies in Israel: A 37-year Follow-up Study." Clinical and Epidemiological Study 40.1 (2012): 35-39
- Yapp, Alvin. "Infection Outcomes in Splenectomized Patients." International Society for Infectious Diseases 13 (2009): 696-700.