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Rapid Responses: Rapid Responses published:
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What about old splenectomies?
- Stephen Sciberras (22 August 2005)
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Autosplenectomy and infection risk
- Vassilios Vassiliou, Ioannis Karydis (23 August 2005)
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Re: What about old splenectomies?
- Adrian C Newland, Drew Provan, Steve Myint (23 August 2005)
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A Question
- Muhammad A Rahim (23 August 2005)
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Sepsis, Splenectomy and Diagnosis
- Paul J Schmidt (25 August 2005)
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Increased malarial & meningitis risks in asplenics
- Harald M Lipman (30 August 2005)
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Authors' reply
- Adrian C Newland, Drew Provan, Steve Myint (30 August 2005)
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incidence of autosplenectomy
- Prashant Mani (7 June 2008)
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Stephen Sciberras, SHO St Luke's Hospital, Malta
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I agree that more awareness from both patients and their doctors is important. One area for which no guidleines exist includes those patients who were operated long time ago (>20) who have never had any vaccines and are not on antibiotic therapy. Any ideas on how to proceed, given that post-splenectomy infections occur mainly in the first two years? Competing interests: None declared |
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Vassilios Vassiliou, Transplant SHO CB2 2QQ, Ioannis Karydis
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Prof. Newland and collegues make a valid point regarding post surgical splenectomy patients and the risk of severe infeciton. However, the same risk holds for patients who are at risk of autosplenectomy, for example, coeliac disease (1) which is also common. Unfortunately, in such patients the awareness for immunisation (2), prophylactic antibiotics and early treatment of infection is even less. (1) Johnston SD, Robinson J.Fatal pneumococcal septicaemia in a coeliac patient. Eur J Gastroenterol Hepatol. 1998 Apr;10(4):353-4. (2) McKinley M, Leibowitz S, Bronzo R, Zanzi I, Weissman G, Schiffman G.Appropriate response to pneumococcal vaccine in celiac sprue.J Clin Gastroenterol. 1995 Mar;20(2):113-6. Competing interests: None declared |
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Adrian C Newland, Professor of Haematology The Royal London Hospital, London , E1 1BB, Drew Provan, Steve Myint
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This is an important point, as many of these patients had surgery at a time when the risks of post operative infection were even less appreciated than at present. Although the majority of infections do occur in the first two years post surgery, most studies will have patients who have had infections as far out as twenty years. At this stage it is worth undertaking a course of immunisations but whether prophylactic antibiotics are necessary is arguable. In theory they should be given, particularly if there is any evidence of immunosuppression i.e. patient on steroids, but at this stage many patients would find it difficult to understand the need and compliance is likely to be low. My policy would be to explain the low level of risk and let the patient have a supply of antibiotics to take if there is evidence of developing infection. Competing interests: None declared |
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Muhammad A Rahim, Clinical Attache Gen Surgery PR2
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The article is a good reading for anyone interested in OPSI and its prevention. One thing which should be looked at is, whether the reduction in incidence of OPSI after two years has any significance or not. If the incidence is reduced after two years, should there be a change in the plan of prophylaxis accrodingly? It can have major implications especially for those patients who would hate the idea to take an antibiotic for the rest of their lives. Thanks. Competing interests: None declared |
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Paul J Schmidt, Consultant Florida Blood Services, PO Box 22500. St Petersburg FL 33742, pauljschmidt@hotmail.com
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After the first description in 1952 of overwhelming sepsis after splenectomy, confirmatory reports followed. Some of them in retrospect were actually reports of boys unrecognized as having Aldrich's Syndrome, a sex-linked recessive disorder with a triad of eczema, thrombocytopenia and fatal sepsis that was first described in 1954. The syndrome was dealt with by splenectomy for the thrombocytopenia and antibiotic prophylaxis was not employed. Fifty years later there is less enthusiasm for removing “accessory” organs such as spleens, young tonsils and aged uteri. There is more replacement therapy, including marrow and stem cells for hematopoietic and immune disorders. However the legacy remains of wrong information from the Aldrich’s cases contributing to the splenectomy calculations. Two brothers were reported as confirmatory splenectomy deaths in 1956.(1) They had been given the diagnosis of Idiopathic Thrombocytopenia Purpura. One was recorded as having eczema as well. Both had died at age six of sepsis within two years of being splenectomized, one in 1952 and the other in 1954; both before Aldrich’s Syndrome was described. 1. Hoefnagel R. Susceptibility to infection after splenectomy performed in childhood. Clin Proc Child Hosp (Washington DC) 1956;12:48- 55. Competing interests: None declared |
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Harald M Lipman, Medical Advisor Travel Health Clinic Number One Health Group, No 1 Harley Street W1G 9QD
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‘Editor I have read your excellent and informative leader of 20/08/05 “Preventing severe infection after splenectomy” and felt that the risks of malarial infection and of meningitis in asplenic travellers were dealt with rather cursorily. Asplenia, from whatever cause, is not uncommon. World-wide travel to malarial areas is probably increasing. Increased risks of falciparum malaria in asplenics, although difficult to quantify,are widely recognised. Fatal outcomes, anecdotally, are increased. I, personally, have heard of three who acquired malaria in West Africa and died. Incidence of meningitis in sub-Saharan Africa, India & Nepal poses significant potential hazards. In my opinion, asplenics should be advised to avoid travel to high- risk malarial areas. As recognised by the Working Party, those who do travel should scrupulously adhere to bite-avoidance measures and appropriate antimalarial prophylaxis. Immediate referral for medical advice is essential should a fever develop. Those travelling to areas with a high incidence of meningitis must be immunised with Meningococcal ACWY vaccine. Harald M Lipman Number One Health Group 1 Harley Street, London W1G 9QD Competing interests: Association with Travel health-screening clinic |
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Adrian C Newland, Professor of Haematology Barts and the London NHS Trust, E1 1BB, Drew Provan, Steve Myint
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Re: Sepsis, Splenectomy and Diagnosis Our leader was written to highlight the risks of infection post- splenectomy. The issue of the appropriateness of the surgery is, of cause, a whole new problem. I agree entirely that unnecessary surgery adds to the patients risks and in thrombocytopenia should not be an early treatment option. This is especially the case in those patients with the more complicated inherited syndromes. Re: Autosplenectomy and infection risk This is an important point to highlight and for reasons of space we were not able to emphasise it in the original article. Autosplenectomy is not uncommon but is not always appreciated and such patients are often at greater risk, as the potential for overwhelming infection may not always be appreciated. It is clear that such patients should always be offered prohylaxis. Re: A Question We did cover this point in the leading article. Although the risks lesson after two years they do not disappear and in the light of any contradictory evidence then patients should be encouraged to take life- long prophylaxis. However, in those patients who are not able to cooperate it is better that they are aware of the dangers, and have a therapeutic supply of antibiotics at home, rather than take prohylaxis in an intermittment and unsatisfactory manner. This can only lead to a false sense of security. Advice differs throughout the world but in the UK the English CMO's advice is for life-long prophylaxis and this is what we currently recommend. In the patient who has had splenectomy and remains immunosuppressed the infection risks are greater and every must be made to persuade them to follow the antibiotic protocol. Re: Increased malarial & meningitis risks in asplenics I am pleased to see this point emphasised. For reasons of space we were not able to give it the importance it deserves, and at a time of increasing travel to 'far flung and exotic' places the risks should be known to those giving travel advice and to the patients themselves. We are all aware of such cases and emphasise the risks to our splenectomised patients. Competing interests: None declared |
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Prashant Mani, ST1 paediatrics MKGH. Milton Keynes, MK6 5LD
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I was interested to know what is the incidence of autosplenectomy in sickle cell patients. What portion of 8- 10 year olds with frequent crises will still have an enlarged spleen? Competing interests: None declared |
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