Case Report


JAP  Volume 7 Issue 1


S


plenectomy is an operation used in the management of patients with one of two pathology groups. Traumatic injury to the spleen can occur with blunt or penetrating


injury to the chest and abdomen, and in patients with haemodynamic instability, urgent splenectomy is often necessary. Splenectomy is also used to treat patients with haematological disease; most commonly idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP) and hereditary spherocytosis (HS). In haematological disease, splenectomy prolongs the erythrocyte and platelet life span, improving the haemolytic anaemia and thrombocytopenia associated with these conditions. Complications of splenectomy include haemorrhage, injury to local structures, wound infection, pneumonia, portal vein thrombosis and overwhelming post- splenectomy infection (OPSI).


“Risk of OPSI is less than 0.5 percent per year, but the mortality rate is at least 50 percent despite best medical therapy”


Vaccination and antibiotic prophylaxis The British Committee for Standards in Haematology (BCSH,


see Table 1) state that splenectomised patients should all be vaccinated, ideally pre-operatively, against Streptococcus pneumonia, Haemophilus influenza type b and Neisseria meningitides with the pneumococcal, Hib conjugate and meningococcal conjugate vaccines respectively. Patients should also be offered yearly influenza vaccination.1 In terms of antibiotic prophylaxis, the BCSH guidelines


advise that patients with a high ongoing risk of pneumococcal infection should be offered lifelong treatment with a penicillin or macrolide. The choice of antibiotic should be reviewed regularly based on local patterns of pneumococcal resistance, and patients should be counselled about the importance of adhering to the recommended therapy and the risks of poor adherence. In patients who are not at high risk, the evidence is not strong enough to recommend lifelong antibiotic prophylaxis in all cases. The greatest danger is early post-splenectomy, and neither prophylaxis nor vaccination eliminate risk entirely; patients should be informed of the advantages and disadvantages and helped to decide whether to continue or discontinue treatment.


Case report A 45-year-old gentleman presented to the Emergency


Department in 2009 with a 12-hour history of malaise, generalised aching, diarrhoea and fever. His only past medical history of note was that he had undergone splenectomy in 1980 for hereditary spherocytosis. He had taken antibiotic prophylaxis for three years post-splenectomy, but was not taking any regular medication on admission. On initial assessment, he was shocked, tachypnoeic, cyanotic


and had a widespread non-blanching purpuric rash. A clinical diagnosis was made of overwhelming post-splenectomy infection (OPSI), and he was commenced on chloramphenicol and ciprofloxacin. Initial blood samples taken in the Emergency Department demonstrated a leukocytosis and a profound metabolic acidosis (pH<6.80). Unfortunately, within minutes of arrival in the Emergency


Department, he suffered a PEA cardiac arrest. He was successfully resuscitated from this event and admitted to the intensive care unit, but suffered a further cardiac arrest one hour later, and resuscitation attempts on this occasion were unsuccessful. Blood cultures taken on arrival in A&E showed heavy growth of Streptococcus pneumonia, though a post mortem examination was unable to locate a source of infection.


Overwhelming post-splenectomy infection Overwhelming post-splenectomy infection (OPSI) is an


uncommon but devastating complication of splenectomy. Risk of OPSI is less than 0.5 percent per year, and approximately five percent over a lifetime,2


percent despite best medical therapy.3 by vaccination and antibiotic prophylaxis as described above.


Conclusions Patients who are asplenic or proven to be hyposplenic should receive the recommended vaccinations stated above, and should also be considered for prophylactic antibiotics on a case-by-case basis. Although the evidence base behind antibiotic prescribing is weak, the constraints of performing a randomised-controlled trial in


Table 1: Summary of BSCH recommendations1


Patients should receive appropriate information and carry a card to alert health professionals to the risk of overwhelming infection


Patients should be educated about the potential risks of overseas travel


Patient records should be clearly labelled to indicate the underlying risk of infection


GPs should maintain a register of at-risk patients


Patients should recieve the pneumococcal, Hib and meningococcal vaccines, and yearly influenza vaccines


Antibody levels may be used to assess response to pheumococcal vaccination and direct timing of pneumococcal revaccination Patients at high risk should be offered lifelong prophylactic antibodies


Patients not at risk should be counselled about the risks and benefits of lifelong antibiotics and may choose to discontinue them


All patients should carry a supply of appropriate antibiotocs for emergency use


Patients developing infection despite the above measures must be given systemic antibodies and admitted urgently to hospital


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but the mortality rate is at least 50 OPSI is largely preventable


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