So You’ve Lost a Spleen: What is a Primary Care Doc to Do?
A Case Study
A 23-year-old had a splenectomy after a motorcycle accident. He received the 23-valent pneumococcal vaccine (PCV23) after surgery and now, 6 months later, he is calling because he has a fever. What should you do?
This month’s Top Paper1 begins with a clinical scenario aimed directly at primary care physicians. The stakes in the asplenic arena are prohibitively high. Patients with postsplenectomy sepsis have a 50% mortality. In fact, the Streptococcus pneumoniae bacteremia experienced by these individuals is so robust that the organisms may be visible in stained blood specimens.
Knowing this, we would treat our patient by prescribing empiric therapy immediately after blood cultures are obtained. This should be parenteral, inpatient therapy with ceftriaxone, with or without vancomycin. This is a medical emergency.
Antibiotics
The Top Paper1 does not lack for any critical detail. If the patient in question is >2 hours distant from a medical facility, 2 g of amoxicillin or 750 mg of levofloxacin should be taken. In fact, lifelong antibiotic therapy is used in survivors of postsplenectomy sepsis. This is not a disease to be trifled with.
However, the primary care practitioner’s responsibility does not end with antibiotics.
Vaccinations
Let’s begin with pneumococcus. First, after or before an elective splenectomy, the 13-valent vaccine (PCV13) should be administered. Eight weeks later, PCV23 is given. Note: This specific sequence, and its booster effect, results in the highest antibody concentration.
If the Haemophilus B vaccine has not been given, it is required in this population as well. This is a single vaccination and is given the same way to splenic and asplenic persons. A 2-dose series of meningococcal polysaccharide is also essential and is administered 8 to 12 weeks apart in recipients >2 years of age (the recommendations for infants are different and are also in the paper). A booster for meningococcus is required every 5 years.
There are other highly at-risk asplenic groups. In children 3 to 36 months of age with sickle cell disease, oral penicillin V 125 mg twice daily reduces the incidence of pneumococcal septicemia by 84%.
Dog Bites
There are even caveats for lovers of man’s best friend. For those without a spleen who are bitten by a dog, a prophylactic antibiotic—eg, penicillin—should be given. The bacterium that accompanies the bite is Capnocytophaga canimorsus, a lethal pathogen in the asplenic demographic.
Since the buck for vaccinations stops with primary care, this Top Paper1 can help fill out important gaps in any practitioner’s knowledge. My approach to asplenic patients will forever be changed to a heightened state of vigilance. ■
Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.
Reference:
1. Rubin LG, Schaffner W. Care of the asplenic patient. N Engl J Med. 2014;371(4):49-56. Interested in past Top Papers? Visit www.consultant360.com to find our archives.