The Spleen and Its Disorders

Published on 04/03/2015 by admin

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Chapter 72 The Spleen and Its Disorders

Nathan T. Connell, Susan B. Shurin, Fred J. Schiffman

Management of Splenic Cysts

A 37-year-old woman with no past medical history comes in for evaluation of early satiety and left shoulder pain. She reports that she feels full after only a few bites of any meal and sometimes becomes nauseated and vomits. Physical examination is remarkable for an enlarged nontender spleen. Imaging shows a large splenic cyst.

• Many conditions can lead to cyst formation in the spleen, including parasitic infections, trauma, hemangiomas, and polycystic kidney disease.

• Asymptomatic nonparasitic cysts may be observed with careful attention and development of a plan for intervention should they become symptomatic, rupture, or become infected.

• Symptomatic cysts may require percutaneous drainage with radiologic guidance or sometimes surgical procedures, including partial or total splenectomy.*

• Parasitic cysts should be treated in consultation with infectious disease specialists because the particular parasitic infection, radiologic appearance, and patient comorbidities will guide choice of therapies.

Figure 72-1 RED BLOOD CELL FINDINGS IN HYPOSPLENISM.

A, Red blood cells with Howell-Jolly bodies. B, Nucleated red blood cell. C, Cells with Pappenheimer bodies. Red blood cells with Howell-Jolly bodies are seen in patients with hyposplenism. The cytoplasmic inclusions (A) are nuclear remnants that are usually round and stain similar to the nucleus of a nucleated red blood cell (B). They occur normally during red cell maturation but are typically removed by a normal spleen. Their presence in the blood indicates less-than-normal splenic function. Pappenheimer bodies (C), which can also be seen in hyposplenism, are siderotic granules that are irregular in shape and frequently multiple.

Timing of Return to Contact Sports in Athletes Who Have Had Infectious Mononucleosis

A 17-year-old male high school student is diagnosed by his primary care physician with infectious mononucleosis. The patient is concerned about the upcoming soccer season and wants to be able to start training with the team in 4 weeks.

• More than half of patients with infectious mononucleosis develop splenomegaly within the first 14 days of illness.

• Most reports of splenic rupture in the setting of infectious mononucleosis occur in the first 21 days of illness.

• There is a paucity of data to support imaging the spleen to document resolution of splenomegaly before returning to contact sports.

• Noncontact sports may be safely resumed after at least 21 days from the onset of initial symptoms, and contact sports should be safe in most cases after at least 28 days. Infectious mononucleosis–associated splenic rupture has been reported as far as 7 weeks after symptom onset.

• The timing of return to sports and the risks should be discussed with the patient, especially if the patient may not have returned to baseline after prolonged fatigue.

Table 72-1 Causes of Splenomegaly

Table 72-2 Incidence of Postsplenectomy Sepsis

Indication for Splenectomy	Cumulative Incidence of Bacterial Sepsis (%)
Trauma	1.5
Hematologic disorders	3.4
Portal hypertension	8.2
Hodgkin disease	10
Sickle cell disease	15
Thalassemia	25

Data from Gorse GJ: The relationship of the spleen to infection. In Bowlder AJ, editor: The spleen: Structure, function, and clinical significance, New York, 1990, Van Nostrand Reinhold, p 269, with permission.

Vaccination of a Patient Scheduled for Elective Versus Emergency Splenectomy

A 50-year-old man with refractory immune thrombocytopenia purpura is scheduled for splenectomy. Having heard that there is a risk for different types of infection after splenectomy, he asks what he can do to reduce his risk.

Patients scheduled for elective splenectomy should receive the following at least 14 days before the procedure:

• Streptococcus pneumoniae vaccine

• Haemophilus influenzae vaccine

• Neisseria meningitis vaccine

Consider administration of the influenza vaccine because influenza is a risk factor for secondary bacterial infection.

If the procedure is done emergently, wait until at least the 14th postoperative day.

^*Troendle SB, Adix L, Crary SE, et al: Laboratory markers of thrombosis risk in children with hereditary spherocytosis. Pediatr Blood Cancer 49:781, 2007.

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