OVERWHELMING POSTSPLENECTOMY INFECTION
Section snippets
THE ROLE OF THE SPLEEN IN THE IMMUNE SYSTEM
The pathogenesis of OPSI lies in the loss of splenic immunologic function. As part of the reticuloendothelial system, splenic function can be divided into several elements: phagocytosis and clearance of unopsonized particulate matter, development of specific immune responses, and production and processing of opsonins.4
The spleen functions as a voluminous filter with strategically placed macrophages. Its extensive, sluggish microcirculation facilitates phagocytosis as splenic lymphoreticular
CONDITIONS PREDISPOSING TO HYPOSPLENISM
OPSI has been associated with asplenia for the full range of indications for splenectomy: malignancy, “benign” hematologic disorders such as hereditary spherocytosis, abdominal trauma, “incidental” splenectomy due to intraoperative injury or en bloc removal during another process.10, 31, 34, 42, 56, 64, 85, 90, 93
The concept of nonsurgical “functional” asplenia39 or hyposplenia occurs in association with disorders such as congenital asplenia, splenic atrophy, and sickle cell anemia. It is also
EPIDEMIOLOGY OF SPLENECTOMY
The importance of OPSI is its excessive morbidity and mortality despite a low incidence. With increased knowledge of the spleen's critical role in disease prevention, the indications for splenectomy have been re-evaluated, and a review of the many published series on splenectomized patients shows an increasingly conservative approach to splenic resection. Overall numbers are decreasing, as well as the percentage of cases for particular indications. This has been seen primarily in two areas:
MORBIDITY AND MORTALITY OF OPSI
Many attempts have been made to delineate the exact nature of the infection and to stratify the risks of developing OPSI. The entity may be best defined as an infection, occurring more commonly after splenectomy (or in a hyposplenic host), which evolves over a short time and produces severe symptoms, often with hypotension and a high mortality rate.85 Delineation is made difficult by the low incidence and by the heterogeneity of the patients who undergo splenectomy. An increased risk of
Bacteria
The predisposition of splenectomized patients for infection with encapsulated bacteria is well documented. Infants and young children are likely to lack exposure to these bacteria, and lacking specific antibody, rely to a greater degree on splenic sequestration and clearance. In the adult, diminished antibody response and splenic clearance contribute to the development of overwhelming infection.83 Although the frequency of causative organisms varies from series to series, published data
PRESENTING SIGNS AND SYMPTOMS
The classical manifestations of OPSI begin with a brief prodrome of fever with mild, nonspecific symptoms, rapidly evolving into overwhelming septic shock. There is usually no evidence of a local tissue infection, and the process is often accompanied by disseminated intravascular coagulation (DIC). In this markedly virulent presentation mortality ranges from 50% to 75%, with death ensuing within 24 to 48 hours.9, 52
This clinical picture has remained disturbingly unchanged. Onset is usually in
CLINICAL AND LABORATORY DIAGNOSTIC TESTING
Initial diagnosis must rely on a high index of clinical suspicion for any febrile presentation in a splenectomized patient because aggressive early management is critical. Diagnostic work-up should never delay the initiation of empiric antibiotic therapy. The most helpful initial test is the examination of the peripheral blood smear (Fig. 1) and buffy coat (Fig. 2) for the presence of bacteria. Visualization of organisms on the peripheral smear suggests a quantitative bacteremia of > 106
TREATMENT MODALITIES AND NEED FOR RAPID THERAPY
The critical point in management remains the early recognition of the patient at risk followed immediately by aggressive intervention. All asplenic patients with fevers of unknown origin should be treated as medical emergencies. Intravenous penicillin has long been the cornerstone of antibiotic therapy because it provides excellent activity against pneumococci and meningococci, frequent causes of fatal infection. But as resistance patterns change, continued reliance on penicillin may be unwise.
PREVENTIVE STRATEGIES
The area where intervention has the greatest potential to decrease the mortality of overwhelming sepsis in asplenic patients is prevention. Studies, however, have documented a poor track record to date for such preventive strategies.25, 80, 88, 102 White et al102 reported awareness of risk in only 11% of an asplenic population. Deodhar et al25 found that less than half of asplenic patients in their series had received pneumococcal vaccine, were on antibiotic prophylaxis, or had even received
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Address reprint requests to Rajendra Kapila, M.D., Division of Infectious Diseases, U.M.D.N.J. - New Jersey Medical School, MSB Room I-509, 185 South Orange Avenue, Newark, NJ 07103
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From the Division of Infectious Diseases, New Jersey Medical School, Newark, New Jersey
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References 1, 8, 9, 31, 42, 64, 78, 85, 90, 92, 98.