Immunological function in post-traumatic splenosis

Asplenia and spleen hypofunction

Asplenia (the congenital or acquired absence of the spleen) and hyposplenism (defective spleen function) are common causes of morbidity and mortality. The spleen is a secondary lymphoid organ that is responsible for the regulation of immune responses and blood filtration. Hence, asplenia or hyposplenism increases susceptibility to severe and invasive infections, especially those sustained by encapsulated bacteria (namely, Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae type b). Asplenia is predominantly due to splenectomy for either traumatic events or oncohaematological conditions. Hyposplenism can be caused by several conditions, including haematological, infectious, autoimmune and gastrointestinal disorders. Anatomical disruption of the spleen and depletion of immune cells, especially IgM memory B cells, seem to be predominantly responsible for the clinical manifestations. Early recognition of hyposplenism and proper management of asplenia are warranted to prevent overwhelming post-splenectomy infections through vaccination and antibiotic prophylaxis. Although recommendations are available, the implementation of vaccination strategies, including more effective and immunogenic vaccines, is needed. Additionally, screening programmes for early detection of hyposplenism in high-risk patients and improvement of patient education are warranted.

Calcification in Thoracic Splenosis

Splenosis is a rare condition described as the implantation of ectopic splenic tissue, usually after a splenic rupture. Thoracic splenosis refers to acquired ectopic splenic tissue found within the thoracic cavity, often caused by thoracoabdominal trauma or surgery. Most cases are asymptomatic and many years may elapse before they are incidentally discovered on chest radiography or thoracic computed tomography. Splenosis is often misinterpreted as a malignancy on initial imaging. We wish to highlight a rare case of thoracic splenosis presenting with calcified and non-calcified nodules. Only two other cases of calcification have been reported in intrathoracic splenosis, neither of which provided CT images of this finding.

Splenosis mimicking gastric obstructive tumor: Diagnostic workup and surgical excision

Splenosis is a condition that occurs after splenic rupture. A 29-year-old male patient with a history of splenectomy was admitted due to multiple vomiting episodes. The diagnostic workup was unable to differentiate between gastric GIST and splenosis. Laparoscopic surgical resection was performed leading to the diagnosis of splenosis.

A case of thoracoabdominal splenosis

We describe a case of a 38-year-old male with a remote history of motor vehicle trauma who presented to the emergency department with 1-week history of progressively worsening abdominal pain localized to the epigastric region. Patient history included splenectomy. Computerized tomography demonstrated multiple masses in the left pleural space as well as masses continuous with the diaphragm and abdominal wall in the left upper quadrant. In addition, a lobulated mass was identified in the right upper quadrant along the anterior right hepatic lobe. A diaphragmatic defect was noted containing splenic tissue. A diagnosis of splenosis was made. Disseminated splenosis presenting in both the thorax and abdomen is rare and poorly documented. This case serves to further illuminate this condition.

Management of intrahepatic splenosis:a case report and review of the literature

Background

Splenosis is the heterotopic autotransplantation and implantation of splenic tissue after splenic trauma or splenectomy. Considering that splenosis often occurs in the mesentery, omentum, and peritoneum, intrahepatic splenosis has seldom been reported. We report a rare case of isolated intrahepatic splenosis in a 54-year-old man who presented with a liver mass thought to be hepatocellular carcinoma.

Case presentation

A 54-year-old man was referred to our hospital for further evaluation of a liver lesion. The patient was asymptomatic and had a history of emergent splenectomy after a high-altitude falling accident. Abdominal contrast-enhanced computed tomography revealed a 4.5 × 3.3 cm lesion that was located in segment IV of the left liver lobe. The lesion had an inhomogeneous enhancement during the arterial phase and diminished enhancement during the portal and equilibrium phases. Similar radiological features were also observed on a contrast magnetic resonance imaging scan. Partial hepatectomy was performed with the suspicion of hepatocellular carcinoma. Pathological examination of the liver specimen revealed intrahepatic splenosis.

Conclusion

Splenosis should be considered in differential diagnosis of a liver mass discovered years after splenic trauma or surgery. A proposed scoring system may be helpful in evaluating the suspicious degree of intrahepatic mass to be splenosis. Invasive treatments are not recommended for asymptomatic patients, since the splenosis can provide beneficial immunologic function.

Focal pleural tumorlike conditions: nodules and masses beyond mesotheliomas and metastasis

A tumorlike condition of the pleura is any nonmalignant lesion of the pleura or within the pleural space that could be confused with a pleural tumor on initial imaging. Tumorlike conditions of the pleura are relatively rare compared with neoplastic lesions such as mesotheliomas and metastases. Imaging-based diagnosis of these conditions can be difficult due to the similarity of appearance. Thus, recognition of certain imaging patterns and interpretation of these patterns in the clinical context are important. Pleural endometriosis, thoracic splenosis, thoracolithiasis, foreign bodies, pleural pseudotumors and pleural plaques are significant examples of focal tumorlike conditions discussed in this article. Computed tomography is the mainstay imaging technique for the primary assessment of pleural disease, but other imaging methods, such as magnetic resonance imaging and positron-emission tomography, can be of great support in the diagnosis.

Vaccination considerations in the asplenic patient

Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.

Alloimmunization to transfused platelets requires priming of CD4+ T cells in the splenic microenvironment in a murine model

BACKGROUND

Alloantibodies are a clinically significant sequelae of platelet (PLT) transfusion, potentially rendering patients refractory to ongoing PLT transfusion support. These antibodies are often IgG class switched, suggesting the involvement of CD4+ T-cell help; however, PLT-specific CD4+ T cells have not been visualized in vivo, and specifics of their stimulation are not completely understood.

STUDY DESIGN AND METHODS

A murine model of alloimmunization to transfused PLTs was developed to allow in vivo assessment and characterization of CD4+ T cells specific for PLT major histocompatibility complex (MHC) alloantigen. PLTs were harvested from BALB/c mice, filter leukoreduced, and transfused into C57BL/6 recipients. PLT-specific CD4+ T-cell responses were visualized by using a T-cell receptor transgenic mouse that detects peptide from donor MHC I presented on recipient MHC II. Antibody responses were determined by indirect immunofluorescence using BALB/c donor targets.

RESULTS

C57BL/6 recipients of BALB/c leukoreduced PLT transfusions produced BALB/c antibodies, with proliferation of antigen-specific CD4+ T cells seen in the spleen but not lymph nodes or liver. Depletion of recipient CD4+ cells or splenectomy independently abrogated the alloantibody response.

CONCLUSION

We report a novel model to study antigen-specific CD4+ T cells during alloimmunization to PLT transfusion. The presented data support a critical role for CD4+ T-cell help in the humoral response to PLT transfusion and establish the spleen as a required microenvironment for effective CD4+ T-cell priming against donor PLT-derived MHC I.

Thoracic splenosis masquerading as bronchial cancer

A 57-year-old woman presented with adhesional small bowel obstruction and required a laparotomy and adhesiolysis. The postoperative period was complicated by pulmonary embolism. In addition, computed tomography (CT) pulmonary angiogram also demonstrated several indeterminate pleural based pulmonary nodules suspicious of a primary malignancy. Review of this patient's past medical history revealed a road traffic collision 29 years previously which required a laparotomy, left nephrectomy, splenectomy, and repair of the left hemi-diaphragm. Radiological surveillance with follow-up chest CT demonstrated stable appearance of the indeterminate nodules, and a diagnosis of thoracic splenosis was considered the most likely explanation of the imaging findings. Thoracic splenosis must be considered in patients presenting with lung nodules and a past history of thoracoabdominal trauma. Radionuclide studies with technetium(99m) (Tc(99m)) sulfur colloid or Tc(99m) heat damaged red cell scans can help confirm or refute this diagnosis and thereby reassure both patient and clinician.

Abdominal splenosis mimicking hepatic tumor: a case report

Diagnosis of abdominal splenosis is often undiagnosed until treatment for splenic rupture or splenectomy. This report describes a patient with splenosis mimicking hepatic tumor. The patient had a history of splenic trauma with splenectomy and chronic hepatitis C. After routine abdominal ultrasound revealed a liver nodule, further imaging studies, including magnetic resonance imaging, computed tomography and angiography, were performed. After the patient eventually underwent surgery, pathology revealed splenic tissue. Despite its distinguishable clinical features, splenosis is difficult to identify by modern imaging modalities. Therefore, accurate and timely diagnosis of this disease requires constant vigilance.

Thoracic splenosis mimicking thoracic schwannoma: case report and review of the literature

BACKGROUND

Thoracic splenosis is a rare entity. It occurs sometime after splenic and diaphragmatic injury, and it is rarely symptomatic.

CASE DESCRIPTION

We report a case of left upper thoracic paraspinal splenosis 25 years after a thoracoabdominal penetrating trauma that required a splenectomy. The pathology was suspected on a routine chest x-ray and it mimicked a schwannoma on magnetic resonance imaging. Less than 40 cases of thoracic splenosis were described in the literature, but few were misinterpreted as schwannoma.

CONCLUSION

Alertness to the possibility of thoracic splenosis can lead to confirmation of the diagnosis with technetium Tc 99m-tagged red blood cell radionuclide scanning based on a previous history of traumatic splenectomy.

[Unspecific abdominal complaints: diagnosis with szintigraphy]

This case report describes a 65-year old man with symptomatic abdominal and pelvic splenosis. 50 Years ago he has had splenectomy after a road traffic accident. Ultrasound and CT revealed a bulky mass in the iliac fossa and multifocal intraabdominal nodules suggesting peritoneal carcinomatosis. Scintigraphy with Tc-99m-labelled heat damaged red blood cells led to definitive diagnosis. RBC-scintigraphy is a specific, easy performable diagnostic tool. It is cost-effective and can avoid other diagnostic procedures or explorative surgery.

Occult gastrointestinal bleeding and abdominal pain due to entero-enteric intussusception caused by splenosis

Intussusception is rare in adults. We report the first known case of adult intussusception caused by splenosis. The patient had chronic gastrointestinal bleeding and intermittent abdominal pain. The diagnosis of entero-enteric intussusception was made by CT scan. A laparoscopic-assisted small bowel resection was performed, leading to resolution of the symptoms.

Aderência e atividade microbicida de monócitos em portadores de esquistossomose mansônica na forma hepatoesplênica cirúrgica

A cirurgia nas crianças portadoras de esquistossomose mansônica inclui esplenectomia, ligadura da veia gástrica esquerda e o auto-implante de tecido esplênico no omento maior. A eficácia desse procedimento pode ser responsável pelo desaparecimento da sepse fulminante pós-esplenectomia (SFPE) neste tipo de paciente. Esta condição é atribuída à diminuição de IgM, de linfócitos circulantes, de properdina e ausência de tuftsina, o que conduz a deficiência da atividade das células macrófágicas, que são responsáveis pela aderência à bactéria, fagocitose e destruição das mesmas. OBJETIVO: Analisar os aspectos funcionais dos monócitos destes pacientes, operados quando crianças, no Serviço de Cirurgia Geral da Criança do Hospital das Clínicas da UFPE, entre 1991 a 2000. MÉTODOS: Foram analisados os índices de aderência in vitro dos monócitos e a geração do ânion superóxido (O2-), em três grupos. O 1º, auto-implante (AI), constituído por 18 portadores de esquistossomose mansônica na forma hepatoesplênica, submetidos a esplenectomia, ligadura da veia gástrica esquerda e auto-implante de tecido esplênico no omento maior; o 2º, (ESP), formado por nove pacientes similares, submetidos a esplenectomia e desconexão ázigo-portal, e o 3º,(CT), constituído por 12 adolescentes sadios, oriundos da mesma condição sócio-econômica-geográfica. RESULTADOS: Não houve diferença no índice de aderência entre os três grupos. Os monócitos dos pacientes do grupo AI tiveram a geração de O2- semelhante à dos indivíduos do grupo CT, e significantemente maior do que os pacientes do grupo ESP. CONCLUSÕES: Os monócitos dos portadores de esquistossomose hepatoesplênica submetidos a esplenectomia, ligadura da veia gástrica esquerda e auto-implante de tecido esplênico no omento maior se mostram funcionalmente similares aos de indivíduos normais da mesma condição sócio-econômica-geográfica.

Was Sampson wrong?

OBJECTIVE

Sampson's theory of reflux menstruation suggests that endometriosis is one form of a condition known as an autotransplant. This study seeks to characterize autotransplants as they are described in the literature and to determine whether endometriosis resembles an autotransplant.

DESIGN

Literature review of published studies containing the following types of information: [1] characterization of the histologic features, immunohistochemistry, or structural function of autotransplants; and [2] comparisons of endometriosis with endometrium.

MAIN OUTCOME MEASURE(S)

Characteristics of multiple types of autotransplants were noted. Similarity or dissimilarity of endometriosis and endometrium was tabulated to judge qualitatively whether the bulk of the evidence supports the notion that endometriosis is an autotransplant.

RESULT(S)

Autotransplants remain very similar or identical to eutopic tissues of origin, regardless of the length of time following autotransplantation. Endometriosis differs in many profound and fundamental ways from eutopic endometrium, including clonality of origin, enzymatic activity, protein expression, and histologic and morphologic characteristics. A minority of studies has found similarities between endometriosis and eutopic endometrium.

CONCLUSION(S)

Endometriosis is dissimilar to eutopic endometrium and therefore lacks characteristics of an autotransplant. Sampson's theory of origin of endometriosis is not supported by the results of this study. Studies of experimental endometriosis that have not used menstrual endometrium may be misleading.

Autotransplant of spleen tissue in children with schistosomiasis: evaluation of splenic function after splenosis

Autotransplantation of spleen tissue has been done, in the past ten years, in children with schistosomiasis mansoni with bleeding varices. The purposes of this investigation were: (1) to study the morphology and function of the remnant spleen tissue; (2) to quantify the production of tuftsin; and (3) to assess the immune response to pneumococcal vaccine of these patients. Twenty three children, who underwent splenectomy and autologous implantation of spleen tissue into the greater omentum were included in this investigation. The average postoperative follow-up is five years. Splenosis was proved by colloid liver-spleen scans. Search for Howell-Jolly bodies assessed the filtration function. Tuftsin and the titer of pneumococcal antibodies were quantified by ELISA. Splenosis was evident in all children; however, it was insufficient in two. Howell-Jolly bodies were found only in these two patients. The mean tuftsin serum concentration (335.0 +/- 29.8 ng/ml) was inside the normal range. The immune response to pneumococcal vaccination was adequate in 15 patients; intermediate in four; and inadequate in four. From the results the following conclusions can be drawn: splenosis was efficient in maintaining the filtration splenic function in more than 90% and produced tuftsin inside the range of normality. It also provided the immunologic splenic response to pneumococcal vaccination in 65% of the patients of this series.

Splenosis presenting as occult gastrointestinal bleeding

A 48-year-old man presented with recurrent gastrointestinal bleeding and anemia. Routine endoscopic evaluation was nondiagnostic. Angiography demonstrated multiple apparent arteriovenous malformations. Exploratory laparotomy revealed numerous splenic implants along the small and large bowels, some of which had apparently eroded through the bowel mucosa and bled. Excision of these penetrating lesions prevented further bleeding. An incidentally noted renal cell cancer was also resected. The patient's splenosis was the result of childhood trauma that caused splenic rupture and precipitated splenectomy. Splenosis develops frequently following traumatic splenic rupture. Experimental evidence suggests that the presence of an intact spleen suppresses the growth and development of splenic implants. Following splenectomy, splenules may replace some of the "housekeeping" and immunologic functions of the spleen, but even patients with documented splenosis should be considered functionally hyposplenic. While in most cases splenules cause no symptoms, splenosis must be considered in the differential diagnosis of previously splenectomized patients who present with unexplained masses or occult bleeding.

Spleen autotransplantation provides restoration of functional splenic lymphoid compartments and improves the humoral immune response to pneumococcal polysaccharide vaccine

After splenectomy, patients have an increased risk of overwhelming post-splenectomy infection (OPSI) or sepsis involving encapsulated bacteria such as pneumococcus. The value of spleen autotransplantation after splenectomy because of trauma has long been questioned. Much attention has been given to the restoration of mononuclear phagocyte system (MPS) function, which appeared to be similar to that of splenectomized individuals. The presence of specific anti-pneumococcal antibodies may enhance phagocytosis of opsonized bacteria by other parts of the MPS, as present in the liver. Therefore, in the present study we have evaluated the restoration of the humoral immune response after spleen autotransplantation, especially to pneumococcal capsular polysaccharides (PPS). Wistar rats were divided into three groups which were operated as follows: splenectomy, splenectomy followed by autotransplantation, and sham operation. After 12 weeks the rats were vaccinated with 23-valent pneumococcal vaccine. Blood samples were taken after 3 days, 3 and 6 weeks for anti-PPS IgM and IgG ELISA against types 3, 4, 6, 9, 14 and 23. In addition, immunohistological studies were performed on the autotransplants. Significant antibody titre rises were found in a main proportion of the autotransplanted rats, comparable to sham-operated rats. Splenectomized rats showed as well a significantly lower increase in immunoglobulin levels, as significant differences in the proportion of rats showing a minimum two-fold increase of antibody level, considered to represent an adequate response. The titres were highest 3 days after vaccination. Immunohistochemical studies demonstrated structurally functional autotransplants, including an intact marginal zone. Considering this significant anti- pneumococcal antibody response, spleen autotransplants can be expected to enable an improved humoral response to PPS, and to contribute to protection against OPSI after splenectomy.

Immune response capacity after human splenic autotransplantation: restoration of response to individual pneumococcal vaccine subtypes

OBJECTIVE

To evaluate features of general immune function, in particular the restoration of the humoral immune response to pneumococcal capsular polysaccharides, in humans undergoing a spleen autotransplantation after splenectomy because of trauma.

SUMMARY BACKGROUND DATA

After splenectomy, patients have an increased risk of overwhelming infection or sepsis involving encapsulated bacteria such as pneumococci. The value of human spleen autotransplantation after splenectomy because of trauma has long been questioned. Mononuclear phagocyte system function appeared to be similar to that in splenectomized persons. The presence of specific antipneumococcal antibodies would allow other parts of the mononuclear phagocyte system, such as those in the liver, to phagocytose opsonized bacteria.

METHODS

Ten consecutive patients undergoing splenectomy followed by autotransplantation were compared with the next 14 consecutive patients undergoing splenectomy alone. After a minimum of 6 months, the patients were vaccinated with 23-valent pneumococcal vaccine. Blood samples were taken at the time of vaccination and after 3 and 6 weeks for antipneumococcal capsular polysaccharides IgM and IgG enzyme-linked immunosorbent assay against types 3, 4, 6, 9, 14, and 23. Splenic regrowth was evaluated by scintigraphy.

RESULTS

Surprisingly, several of the nonautotransplanted patients showed scintigraphic activity, indicating the presence of either accessory spleens or traumatic seeding (splenosis). Significant antibody titer increases (more than twofold) were found for both IgM and IgG in the autotransplanted patients. Splenectomized-only patients showed no significant increase in Ig levels in patients without splenic regrowth and partial improvement in patients with splenosis/accessory spleens.

CONCLUSIONS

Considering this significant antipneumococcal antibody increase, spleen autotransplants can be expected to permit an adequate humoral response to pneumococcal infections and presumably also to other TI-2 antigens, and to protect against overwhelming postsplenectomy infection or sepsis.

Esquistossomose hepato-esplênica em crianças: avaliaçao morfológica e funcional após esplenectomia e auto-implante esplênico

A esquistossomose mansônica hepato-esplênica com varizes sangrantes do esôfago é infreqüente em crianças, entretanto, determina morbidade atingindo a produtividade desses futuros adultos. Uma das opções para o tratamento cirúrgico é a esplenectomia associada à ligadura da veia gástrica esquerda e esclerose endoscópica das varizes, nos casos de recidiva hemorrágica. Auto-implante esplênico tem sido adicionado em crianças. Há evidências de que a esplenose pós-esplenectomia por trauma mantém, de forma parcial, as funções imunológica e de filtração esplênicas. Todavia, estudos semelhantes não foram realizados em pacientes esquistossomóticos. Foram analisados 23 pacientes, de 9 a 18 anos, com esquistossomose hepato-esplênica submetidos à esplenectomia, ligadura de veia gástrica esquerda e auto-implante esplênico no omento maior. Avaliou-se a função de filtração através da pesquisa de corpúsculos de Howell-Jolly em esfregaços de sangue periférico, cuja presença indica ausência ou insuficiência de função de filtração esplênica. Foi realizada análise morfológica da esplenose através de exame cintilográfico, usando enxofre coloidal, marcado com Tecnécio 99m. Observou-se captação dos implantes esplênicos em todos os pacientes, entretanto, em dois (8,7%), o número de nódulos esplênicos observados foi inferior a cinco, sendo considerado insuficiente. Em correspondência, esses dois pacientes foram os únicos que apresentaram positividade para corpúsculos de Howell-Jolly. Os dados confirmam o auto-implante esplênico no omento maior como método eficaz de produção de esplenose e manutenção da função de filtração esplênica em mais de 90% dos pacientes.

Autotransplantation of spleen tissue in children with mansonic schistosomiasis who underwent splenectomy: Evaluation of splenic residual functions

Autotransplantation of spleen tissue is an attempt for maintenance of splenic functions when splenectomy is indicated in children. It minimizes the risks of overwhelming postsplenectomy infection and it has been done in children with severe portal hypertension due to hepatosplenic mansonic schistosomiasis that underwent splenectomy. The purposes of this investigation were to study the morphology of the residual splenic tissue; to evaluate the residual filtration function of this splenosis; and to assess the immune response to polyvalent pneumococcal vaccine of these patients. Twenty-three children with portal hypertension from mansonic schistosomiasis who underwent splenectomy, ligature of the left gastric vein, autotransplantation of spleen tissue into an omental pouch were evaluated for residual splenic parenchyma and functions. Tc-99m sulfur colloid liver-spleen scans were used for detection of splenic nodules. The search for Howell Jolly bodies were used for assessing the filtration function and Enzyme-linked immunosorbent assay was used for measuring the relative rise in titter of specific pneumococcal antibodies. Splenosis was evident in all children; however, in two there were less than five splenic nodules in the greater omentum, which was considered insufficient. Howell-Jolly bodies were found in the peripheral blood only in these two patients with less evident splenosis. The immune response was adequate in 15 patients; it was intermediate in 4 patients and inadequate in 4 patients. Autotransplantation of spleen tissue into an omental pouch is efficient in maintaining the filtration splenic function in more than 90% of the cases and the immune response to pneumococcal vaccination in approximately 65% of the children.