Cases Of Overwhelming Postsplenectomy Infection Research Articles

＜Editors' Choice＞ Long-term outcomes of the partial splenectomy for hypersplenism after portoenterostomy of patients with biliary atresia.

ABSTRACTMassive splenomegaly and hypersplenism in patients with biliary atresia after Kasai portoenterostomy were treated with partial splenic embolization or total splenectomy. We performed partial splenectomy to reduce the complications of partial splenic embolization and avoid overwhelming post-splenectomy infection. This study aimed to evaluate the long-term effects of partial splenectomy for hypersplenism on postoperative liver and spleen function in patients with biliary atresia. Among jaundice-free patients with biliary atresia who underwent Kasai portoenterostomy between January 1992 and December 2012, 15 underwent partial splenectomy for massive splenomegaly and hypersplenism at our institution. Changes in the laboratory data 10 years post partial splenectomy were retrospectively investigated, and these along with the latest data were measured. A total of four patients (27%) required living-donor liver transplantation after partial splenectomy, a proportion similar to those who did not undergo partial splenectomy. Compared to the preoperative baseline, the platelet counts were significantly higher at 1 and 3 years after surgery (p < 0.05). Aspartic aminotransferase-to-platelet ratio index was significantly lower at 1, 7, and 10 years after partial splenectomy (p < 0.05). No further surgeries were required for hypersplenism after partial splenectomy over 10 years, and there were no cases of overwhelming post-splenectomy infection after partial splenectomy. Partial splenectomy is safe and effective for the treatment of hypersplenism with biliary atresia over a long time period. It could be considered as an alternative to partial splenic embolization as it can suppress hypersplenism for a long time and induces fewer postoperative complications.

SPLENECTOMY IN PAEDIATRIC AGE GROUP

Background: In view of splenectomy in dealing with certain clinical problems in paediatric age group. Objective: To describe the profile, indications, post-operative management and outcomes of children undergoing splenectomy. Methods: All children undergoing splenectomy from June’2019 till August’2021 at INDEX MEDICAL COLLEGE, INDORE, M.P. Results: The mean age at surgery was 9.9 years (range 3-16). Most splenectomies were per-formed for haematological disorders and were open .The mean post-operative length of stay (LOS) in patients who underwent open surgery was 4 days. No cases of overwhelming post splenectomy infec-tion (OPSI) were noted. At study completion, haematological disorders were the most common indication for splenectomy in children. Conclusion: Indications for paediatric splenectomy mirror those found in international litera-ture. We haven't performed splenectomy, laparoscopically. Within this short span of time, no mortal-ity was recorded. We did not have any case of OPSI. Key words: splenectomy

A case of overwhelming postsplenectomy infection by fluoroquinolone-resistant noncapsulated Neisseria meningitidis

A case of overwhelming postsplenectomy infection by fluoroquinolone-resistant noncapsulated <i>Neisseria meningitidis</i>

Autologous Splenocyte Reinfusion Improves Antibody-Mediated Immune Response to the 23-Valent Pneumococcal Polysaccharide-Based Vaccine in Splenectomized Mice.

Common clinical options, currently, for necessary splenectomy are vaccinations and antibiotic prophylaxis. However, despite these two adjuncts, there still occur numerous cases of overwhelming post-splenectomy infection. To examine whether reperfusion of critical splenic lymphocytes could boost immune response, we harvested splenic lymphocytes, reperfused the autologous lymphocytes, and then administered a pneumococcal vaccine (PNEUMOVAX®23, i.e., PPSV23) in splenectomized mice. We found that splenectomy impaired the immune response in the splenectomized group compared to the non-splenectomized group; the splenectomized group with lymphocyte reinfusion had a higher response to polysaccharide vaccination based on antibody titer than the splenectomized group without lymphocyte reinfusion. The sham group with the native spleen had the most elevated antibody titer against the PPSV23 polysaccharide antigen. This may be additive, resulting from contributions of the splenic structure, along with the phagocytic function of the spleen and its constituent cells affecting the antibody response. Reinfusion of splenic lymphocytes may enhance immunity without the complications associated with splenic fragment autotransplantation, which never gained acceptance. This technique is safe and simple since the splenic lymphocytes are autologous and, therefore, not self-reactive, and very similar to autologous blood transfusion. This concept may be beneficial in cases of unavoidable splenectomy, especially in pediatric cases.

Splenectomy in childhood for non-malignant haematologic disorders - long-term follow-up shows minimal adverse effects.

Splenectomy is considered therapeutic in various non-malignant haematologic diseases. Adverse events - specifically infections and thromboembolism - are not extensively documented in the paediatric population, maintaining the concern over risks-versus-benefits of the procedure. We studied a cohort of paediatric haematology patients undergoing splenectomy between 1977 and 2015 to determine short- and long-term complications. We summarised all the patients of the haematology clinic in our major Israeli tertiary centre undergoing splenectomy for therapeutic reasons, capturing infectious and thromboembolic events. The data of 103 patients, comprising 1657 follow-up years, were analysed. The cohort included 33 patients with transfusion-dependent thalassaemia, seven with non-transfusion-dependent thalassaemia, four with sickle-thalassaemia, 41 with hereditary spherocytosis, and 18 with immune thrombocytopenia. Standard presplenectomy vaccinations were noted in most. No typical cases of overwhelming postsplenectomy infection (OPSI) were identified, nor were typical OPSI bacteria isolated. Thalassaemics with central lines were most prone to infection and thrombosis. Beyond this subgroup, thrombotic events were anecdotal. This is the largest study to date to comprehensively analyse infectious and thrombotic complications of childhood splenectomy for the treatment of haematologic diseases. The use of splenectomy appears to be a relatively safe therapeutic option in paediatric patients with proper preoperative vaccination and follow-up care; use of central venous lines or catheters increase the risk in thalassaemic patients and should be avoided if possible.

Paediatric splenectomy: The Johannesburg experience

Background. Splenectomy is an uncommon procedure in children, and data on children who underwent splenectomy in South Africa are sparse. Objective. To describe the profile, operative management and outcomes of children undergoing splenectomy. Methods. The records for all children aged 0 to 16 years who underwent splenectomy at Charlotte Maxeke Johannesburg Academic (CMJAH) and Chris Hani Baragwanath Academic (CHBAH) hospitals between 2000 and 2015 were reviewed. Student’s t -tests and χ 2 tests were used to analyse the data. Results. The mean age at surgery was 9.9 years (range 3-16). Most splenectomies (91%; n =30/33) were performed for haematological disorders and were open (67%; n =22/33). The mean post-operative length of stay (LOS) was shorter in the laparoscopic (4.5 days) than the open (7.1 days) groups ( p <0.05). Surgical complications were more common in the laparoscopic (36%, 4/11) than open (9%; n =2/22) group, and in children older than the mean age at time of surgery. No cases of overwhelming post splenectomy infection (OPSI) were noted. At study completion, 61% ( n =20/33) of patients were alive, 9% ( n =3/33) had demised, and 30% ( n =10/33) were lost to follow-up. Conclusion. Local indications for paediatric splenectomy mirror those found in international literature. Mean and median postoperative lengths of stay (LOS) were shorter in the laparoscopic than open group, but relatively longer for both groups than reported internationally. Laparoscopy is not currently the preferred technique for splenectomy in our setting. All mortalities were due to progression of underlying disease and no cases of OPSI were recorded. The high loss-to-follow-up rate in this study is a significant barrier to accurate data collection, analysis and reporting.

Adherence to infection prevention measures in a statewide spleen registry.

To assess self-reported adherence to measures for preventing infection in patients registered in the Victorian Spleen Registry (VSR). Cross-sectional survey in May 2010 of all patients who had been registered on the VSR for at least 5 months, were able to speak English, and were not living in an institution. Rates of prophylactic antibiotic use, having an emergency supply of antibiotics available, receipt of any recommended booster vaccination (in patients at > 5 years since splenectomy) and receipt of 2009 influenza vaccination. 1175 patients were sent questionnaires, of whom 889 (75.7%) responded. Self-reported adherence to taking prophylactic antibiotics was lower with time since splenectomy (82.9% for < 2 years since splenectomy, 27.4% for ≥ 30 years), as was having an emergency supply of antibiotics available (74.4% for < 2 years and 60% for ≥ 30 years since splenectomy). The proportion receiving the seasonal influenza vaccine and recent booster vaccines (for those at > 5 years since splenectomy) was high. Of patients registered for more than 12 months, 37.0% reported an infection requiring additional antibiotics within the prior year, and 26.1% of these required hospitalisation (including one with a case of overwhelming postsplenectomy infection [OPSI]). Use of prophylactic antibiotics was inversely associated with the rate of infections requiring additional antibiotic therapy (odds ratio, 0.75; 95% CI, 0.57-0.98; P = 0.036). The proportion of VSR registrants adhering to current postsplenectomy guidelines was higher than rates reported elsewhere, and over a third reported infections requiring a course of antibiotics within the prior 12 months. However, only one OPSI occurred. These results support the view that a spleen registry can promote health maintenance behaviour in asplenic patients, which is likely to help prevent serious infections.

Overwhelming Postsplenectomy Sepsis Presenting as Purpura Fulminans due to Streptococcus Suis Infection

Splenectomised patients are more likely to suffer from severe infections, such as sepsis and meningitis. This condition is called overwhelming postsplenectomy infection (OPSI) syndrome. The risk of OPSI is greatest in the early months, and even years, after the operation, but never disappears entirely. The course of OSPI is rapid, the clinical presentations serious, and the prognosis poor. We present here a case of OPSI in a posttraumatic splenectomised adult who had features of fulminant sepsis such as hypotension, renal and liver failure, coagulopathy, and generalised skin rash presented as purpura fulminans. The culprit was found to be Streptococcus suis by the polymerase chain reaction technique. By reporting this case, we hope to emphasize the importance of preventive strategies: vaccination, antibiotic prophylaxis, and patient education. The management of Streptococcus suis infection and the use of 16S rRNA gene sequencing for bacterial identification were also highlighted.

Splenectomy and sepsis

hro su tho French an T ughout the ages, the function of the spleen was bject to much conjecture. It was variously ught to be both the centre of melancholy by the d the centre for anger by the English (“to vent one’s spleen”). Of no doubt was that if the spleen was ruptured, survival was unlikely. Modern surgery has allowed the survival of patients with a ruptured spleen, usually following trauma, by performing a splenectomy, thus preventing further haemorrhage. For a long time after the procedure was perfected, it was thought to have little, if any, long-term consequence, with the spleen considered a rather redundant organ like the appendix. From early last century, it became apparent that splenectomy increased the risk of infection, particularly with encapsulated organisms such as Streptococcus pneumoniae, and increased mortality in malaria. It is now known that, far from being useless, the spleen plays a complex role in the maintenance of normal immune function producing IgM memory B cells, sequestering opsonised encapsulated bacteria and modulating the deleterious effects of cytokines released during sepsis. The article by Dendle and colleagues1 in this issue of the Journal uses administrative data collected across all Victorian hospitals to define postsplenectomy infection rates in Victoria, with some risk stratification, to attempt to inform further infection prevention efforts. It shows that the highest risks for severe sepsis occur among older patients who undergo a splenectomy for haematological malignancy. This comes as no surprise, as these patients are already at high risk given their underlying condition. However, the main weakness in this article is its inability to define the attributable morbidity associated with splenectomy in this group. Overwhelming postsplenectomy infection is a rare but frequently fatal complication, usually caused by Streptococcus pneumoniae. Vaccinations against pneumococcus, Haemophilus influenzae and Neisseria meningitidis are widely recommended as a low-risk intervention that can be applied relatively easily in the hospital setting. Despite this, data from a Victorian hospital published in 1990 showed that only two-thirds of multitrauma patients and as few as 11% of patients with an incidental splenectomy were offered vaccination.2 This illustrated the n of splenectomy through my registry, pioneered in a Hospital, Brisbane, all patients undergoing splenectomy are automatically referred to the infection management service by the operating theatre electronic record. Vaccinations are offered and administered, together with counselling and information about infection risk. We estimate near 100% coverage over the past 10 years (unpublished data). Antibiotic prophylaxis has been a more controversial intervention, particularly among patients with lower risks of postsplenectomy sepsis, such as adults, or those having a splenectomy for trauma without other comorbidities associated with immunosuppression. Traditionally, oral penicillin has been used for its activity against S. pneumoniae. Increasingly, penicillin non-susceptible strains of S. pneumoniae pose a theoretical risk to this regimen. Cases of overwhelming postsplenectomy infection caused by such strains are yet to be reported. In the study by Dendle and colleagues, the predominant pathogens were Staphylococcus aureus and gram-negative bacteria, as would be expected in most bloodstream infection datasets. These organisms would not generally be susceptible to penicillin. The study provides a broad insight into infection outcomes in splenectomised individuals in contemporary Australia. In order to develop modern evidence-based recommendations for vaccination and prophylactic antibiotic regimens, future prospective studies will need to determine the attributable risk of the various types of infection from splenectomy in diverse patient groups. This will allow a calculation of the potential reduction in morbidity and mortality with both vaccination and antibiotic prophylaxis. Adverse effects from broader spectrum antibiotic regimens such as antibiotic resistance and Clostridium difficile-associated diarrhoea would also need to be considered, and the practical issue of compliance with years of antibiotic prophylaxis cannot be overlooked. The relative contribution of education to preventing infectionrelated morbidity also needs to be quantified. The improvements in infection rates following the introduction of the Victorian Spleen Registry are encouraging in this regard, although cause and effect cannot be proven.

Overwhelming postsplenectomy infection due to Mycoplasma pneumoniaein an asplenic cirrhotic patient: Case report

BackgroundMycoplasma pneumoniae infection is usually self-limited, but some fulminant cases are fatal, even when occurring in previously healthy individuals. It can also be the cause of overwhelming postsplenectomy infection (OPSI).Case presentationWe report a case of OPSI in a 41-year-old woman with hypersplenism associated with hepatitis B cirrhosis. We detected a significant Mycoplasma pneumoniae agglutination titer, but no evidence of infection with Chlamydia pneumoniae, Legionnella spp., or any other bacterial or fungal pathogens. She eventually died despite aggressive therapy.ConclusionsM. pneumoniae could be an underestimated cause of OPSI, and should be suspected in fulminant infectious cases in asplenic patients.

REPORT OF AN UNUSUAL CASE OF PERSISTENT BACTEREMIA BY BARTONELLA BACILLIFORMIS IN A SPLENECTOMIZED PATIENT

We report a case of a 56-year-old man with a history of splenectomy for idiopathic thrombocytopenic purpura who developed persistent bacteremia in the acute phase of human bartonellosis. This patient did not develop hemolytic anemia. Only after several courses of antibiotic treatment was the infection eradicated. This is an unusual case of overwhelming post-splenectomy infection by Bartonella bacilliformis, which provides clinical evidence that the spleen is a critical effector organ of clearance of this infection as well as the effector organ of bartonellosis-associated hemolytic anemia.

An audit of splenectomies in a teaching hospital in North India. Are postsplenectomy guidelines being complied with?

Aims: Patients with an absent or dysfunctional spleen are at risk of infection by encapsulated and other bacteria. Overwhelming postsplenectomy infection (OPSI) causes most concern because it can result in...

Overwhelming infection in asplenic patients: current best practice preventive measures are not being followed

Aims—Patients without spleens are at increased risk of overwhelming infection. Recently, greater efforts, including the publication of national guidelines, have been made to improve the management of asplenic individuals. In...

Splenic surgery in childhood

In recent years efforts have been made to preserve the spleen after childhood injuries because of the increased risk of lethal sepsis following childhood splenectomy. The recent literature reveals that overwhelming postsplenectomy infection (OPSI) occurs with an incidence of 3.2% among splenectomized children, with a mortality of 45%. The incidence of OPSI is highest between birth and 2 years; children whose splenectomy was due to trauma had an incidence of 1.5%. OPSI after splenectomy for other diseases results in a higher incidence (5.6%). The case mortality rates are 17.6% and 55.6%, respectively. Splenic rupture constitutes an indication for total splenectomy, particularly when the rapture involves the splenic hilum (stage IV rupture, Barret et al. [1]). We performed anatomic studies of the splenic arterial supply, which showed that an identifiable superior splenic artery served the upper splenic pole in 60% of cases, offering the possibility that the upper pole might be salvaged even in cases of serious rupture. We report a series of 23 children treated for splenic injury in the last 5 years. Using fibrin-glueing techniques in stage I and II ruptures and segmental or subtotal resection in Stage III and IV ruptures, we successfully preserved functioning splenic tissue in every patient, even in cases of complete rupture of the main splenic artery. Functional preservation was documented by splenic scintigraphy and screening for hematologic signs of hyposplenism. Spleen ultrasonography was also performed as an additional follow-up examination. We observed no cases of OPSI in the above-mentioned series.

Overwhelming postsplenectomy sepsis in childhood

Three hundred ninety-three splenectomies were performed within the Charity Hospital system during the decade from 1969 through 1979. This number included 56 operations in children under 16 years of age, which formed the basis of this report of the risk of infection in young splenectomized patients and provided guidelines for the role of splenectomy under emergency and elective conditions. Eight episodes of serious infection were documented in four patients. There was only one case of overwhelming postsplenectomy infection which resulted in death, for a mortality rate of 1.8 percent (1 of 56 children) for death due to overwhelming postsplenectomy sepsis. It is emphasized, however, that the development of serious postsplenectomy sepsis in our series resulted in a 25 percent mortality rate. The risk of postsplenectomy sepsis is much greater in those individuals who are immunologically compromised, such as those who undergo staging splenectomy for Hodgkin's disease. If splenectomy is indicated for a hematologic disorder, it is wise to defer operation for as long as possible, especially if the acute episodes are self-limiting or mild. Rather than the promiscuous use of polyvalent serum and antibiotic therapy after splenectomy in children, it is recommended that parents be advised to bring the child to the hospital anytime an illness or fever develops that might require an immediate loading dose of an appropriate antibiotic. The role of subtotal splenectomy or hemisplenectomy merits consideration in staging Hodgkin's disease. Preoperative study of certain immunologic parameters may provide guidelines as to the proportion of individuals who may be vulnerable to overwhelming sepsis after splenectomy.

Pneumococcal Vaccine and Splenectomy

To the Editor.— Regarding the answer in the QUESTIONS AND ANSWERS section by Theodore H. Spaet, MD (242:1413, 1979), I want to comment on the efficacy of pneumococcal vaccine in the spleenless patients. General studies and reports pertinent to the value of the vaccine in asplenic patients have been published. Asplenic patients are at increased risk from infections caused by encapsulated bacteria, particularlyStreptococcus pneumoniae, Haemophilus influenzaetype B, andNeisseria meningitidis. Overwhelming postsplenectomy infection has been noted in all clinical conditions associated with absence of splenic function. The clinical course is frequently fulminant, leading to disseminated intravascular coagulation and death. Sullivan et al1studied immune response in nine patients aged 4 to 37 years who had undergone splenectomy after trauma. All of these patients demonstrated significant seroconversion in response to pneumococcal polysaccharide antigen. Since the majority of cases of overwhelming postsplenectomy infection are caused byS pneumoniae, all

IMMUNE RESPONSE AFTER SPLENECTOMY

The immune response to intravenously administered bacteriophage ΦX 174 and subcutaneously administered tridecavalent pneumococcal polysaccharide vaccine was studied in 31 patients with anatomical or functional asplenia. Antibody responses to primary immunisation with ΦX 174 were significantly decreased while clearance was normal. Secondary responses were quantitatively normal; however, production of antibody did not switch from IgM to IgG as seen in controls. All groups of asplenic patients except those patients with Hodgkin's disease demonstrated significant seroconversions in response to pneumococcal polysaccharide antigens. One patient with Hodgkin's disease, treated with local irradiation only, demonstrated normal responses to pneumococcal capsular antigens. 10 of the 12 capsular antigens for which antibody was measured stimulated threefold increases in antibody in the 26 asplenic patients without Hodgkin's disease, which is similar to that observed in controls. Since the majority of cases of overwhelming postsplenectomy infection are caused by Streptococcus pneumoniœ,all patients with either anatomical or functional asplenia should receive pneumococcal polysaccharide vaccine.