Page 22 - Delaware Medical Journal - March 2018
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Fulminant Sepsis in the Asplenic Patient — A Physician’s Guide to Identifying, Treating and Managing Patients with Asplenia
Jeena Zachariah, MD; John D’Ambrosio, DO
CASE PRESENTATION
medical history presented to the Emergency Department with a chief complaint of generalized pain, fever, and diarrhea for the past two days. According to the patient’s wife, two days prior to arrival the patient was in good health and suddenly while driving he experienced severe rigors and chills which prompted him to go to a nearby urgent care for evaluation. The patient was home with the presumed diagnosis of noticed that his face had started to develop
a purplish hue and he began having diarrhea as well. The patients’ wife thought he might and decided to bring him to the Emergency Department. Upon arrival, the patient
was found to be persistently hypotensive, tachypneic, tachycardic with an initial saturation was undetectable given he was mottled and cold peripherally. Upon review of the patient’s labs, he was found to have leukopenia, bandemia, thrompocytopenia, lactic acidosis, and was in fulminant disseminated intravascular coagulopathy (DIC). On inspection of his CT Abdomen and Pelvis, the patient was noted to be asplenic and on further review of his CBC and differential, the presence of Howell- Jolly bodies was noted. Despite adequate broad spectrum antibiotics, hemodialysis, ventilator and pressor support, the patient continued to deteriorate and unfortunately passed away the following morning. Blood cultures returned positive for Streptococcus
FIGURE 1
age and anatomical asplenia secondary to
Congenital asplenia is rare and can be isolated. However, it is more commonly associated with other anomalies such as the congenital heart disease Ivemark syndrome.2
Sepsis in the asplenic patient is
rapidly progressive and fatal. The
major differential for infectious organisms involved are Neisseria meningitidis, streptococcus pneumoniae, streptococcus pyogenes, staphylococcus capnocytophagia5 with the latter being more common after a dog bite.
Streptococcus pneumonia infection is the most common cause of fulminant infection in the asplenic host, with an incidence of since the introduction of the 23-valent pneumococcal polysaccharide vaccine in vaccine in 2000, and the 13-valent pneumococcal conjugate vaccine in 2010.2
The presence of Howell-Jolly bodies, thrombocytosis, lymphocytosis, and monocytosis can all be found on the peripheral smear of patients with a dysfunctional spleen. Howell-Jolly bodies are small, intra-erythrocytic remnants of erythrocyte nuclei. A normally functioning spleen will remove these remnants from the erythrocyte, so their presence is pathognomonic for splenic dysfunction.
Daily Therapy and Antibiotics for Fever
Daily antibiotic therapy can greatly reduce the risk of infection and death, especially in children, after splenectomy. Children with sickle cell anemia who have impaired
Howell-Jolly Bodies
pneumonia. Autopsy reports revealed bilateral adrenal hemorrhagic infarcts and cause of death was determined to be septic shock secondary to streptococcus pneumonia.
DISCUSSION
This case displays a typical presentation of fulminant sepsis in an asplenic patient. The key learning point is to prevent morbidity and mortality by having a high index of suspicion to diagnose and treat sepsis in the asplenic patient.
There are a variety of causes of asplenia, including surgical, functional, and congenital asplenia. The most common cause of asplenia is surgical asplenia secondary to trauma, which is usually
found in an otherwise healthy individual. Surgical asplenia may also be found in patients with an underlying hematological or immunological indication for splenectomy, such as sickle cell disease, hereditary spherocytosis, immune thrombocytopenic purpura or hypersplenism. In patients with sickle cell disease, functional asplenia typically develops by about one year of
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Del Med J | March 2018 | Vol. 90 | No. 3
