Clinical features and management of sepsis in the asplenic patient
- Mark S Pasternack, MD
Mark S Pasternack, MD
- Associate Professor of Pediatrics
- Harvard Medical School
- Section Editors
- Peter F Weller, MD, MACP
Peter F Weller, MD, MACP
- Editor-in-Chief — Infectious Diseases
- Section Editor — Tropical Medicine
- William Bosworth Castle Professor of Medicine
- Harvard Medical School
- Professor of Immunology and Infectious Diseases
- Harvard T. H. Chan School of Public Health
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
Splenic function is lost when the spleen has been surgically removed, is congenitally absent, has atrophied following repeated infarction (eg, sickle cell disease), or has infarcted following splenic artery thrombosis (including therapeutic embolization for splenic hemorrhage). In addition, splenic function is reduced in the neonate and may be abnormally reduced (ie, hyposplenism or functional asplenia) when the spleen is engorged with blood (eg, splenic sequestration crisis associated with sickle cell disease, malaria, splenic vein thrombosis) or infiltrated (eg, sarcoidosis, amyloidosis, tumors, or cysts). (See "Approach to the adult patient with splenomegaly and other splenic disorders".)
Asplenic patients and those with impaired splenic function are at risk for a fulminant sepsis syndrome, usually due to Streptococcus pneumoniae. The importance of the spleen for clearance of bacteria and humoral immune response, conditions leading to asplenia, clinical manifestations of infection in the asplenic patient, and the management of postsplenectomy sepsis will be reviewed here. The terms "postsplenectomy sepsis" and "asplenic sepsis" are largely interchangeable, since the functional defects are the same regardless of whether the causative process is congenital or acquired. In this topic review, we will use the term "asplenic sepsis" to include all asplenic patients.
The prevention of sepsis in the asplenic patient is discussed separately. (See "Prevention of sepsis in the asplenic patient".)
ROLE OF THE SPLEEN IN HOST DEFENSE
The sinusoids of the spleen serve as a "fine tooth comb" to filter blood through a series of capillaries as small as 1 micron in diameter to sequester senescent, rigid erythrocytes from the circulation. The mononuclear phagocytes located within this capillary network also ingest circulating bacteria, particularly unopsonized organisms, thus cleansing the roughly 6 percent of cardiac output that perfuses the spleen . The spleen also serves as the largest lymphoid organ within the body and contains nearly half of the body's total immunoglobulin-producing B lymphocytes. Thus, the spleen not only clears bacteria from the circulation but also processes this foreign material to stimulate the production of opsonizing antibody. This function is particularly important in the clearance of encapsulated organisms.
CAUSES OF IMPAIRED SPLENIC FUNCTION
Impaired splenic function can result from splenic disease (hyposplenism) or, more commonly, splenectomy. The causes of splenic disease include:
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- ROLE OF THE SPLEEN IN HOST DEFENSE
- CAUSES OF IMPAIRED SPLENIC FUNCTION
- BACTERIAL PATHOGENS
- RISK OF OTHER INFECTIONS
- Parasitic infections
- Cytomegalovirus infections
- Other causes
- CLINICAL MANIFESTATIONS
- Physical examination
- Laboratory findings
- Empiric antibiotics
- - Adults
- Beta-lactam allergy
- - Children
- Adjuvant dexamethasone for meningitis
- Intravenous immune globulin
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Clinical features