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Ladhani SN, Fernandes S, Garg M, Borrow R, de Lusignan S, Bolton-Maggs PHB. Prevention and treatment of infection in patients with an absent or hypofunctional spleen: A British Society for Haematology guideline. Br J Haematol 2024; 204:1672-1686. [PMID: 38600782 DOI: 10.1111/bjh.19361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/12/2024]
Abstract
Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were published by the British Committee for Standards in Haematology in 1996 and updated in 2002 and 2011. With advances in vaccinations and changes in patterns of infection, the guidelines required updating. Key aspects included in this guideline are the identification of patients at risk of infection, patient education and information and immunisation schedules. This guideline does not address the non-infective complications of splenectomy or functional hyposplenism (FH). This replaces previous guidelines and significantly revises the recommendations related to immunisation. Patients at risk include those who have undergone surgical removal of the spleen, including partial splenectomy and splenic embolisation, and those with medical conditions that predispose to FH. Immunisations should include those against Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus) and influenza. Haemophilus influenzae type b (Hib) is part of the infant immunisation schedule and is no longer required for older hyposplenic patients. Treatment of suspected or proven infections should be based on local protocols and consider relevant anti-microbial resistance patterns. The education of patients and their medical practitioners is essential, particularly in relation to the risk of serious infection and its prevention. Further research is required to establish the effectiveness of vaccinations in hyposplenic patients; infective episodes should be regularly audited. There is no single group ideally placed to conduct audits into complications arising from hyposplenism, highlighting a need for a national registry, as has proved very successful in Australia or alternatively, the establishment of appropriate multidisciplinary networks.
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Affiliation(s)
- Shamez N Ladhani
- Centre for Neonatal and Paediatric Infections (CNPI), St. George's University of London, London, UK
- Immunisation and Countermeasures Division, UK Health Security Agency Colindale, London, UK
| | - Savio Fernandes
- Department of Haematology, Dudley Group Foundation NHS Trust, Russell's Hall Hospital, Dudley, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
| | - Ray Borrow
- Vaccine Evaluation Unit, UK Health Security Agency, Manchester Royal Infirmary, Manchester, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), University of Oxford, Oxford, UK
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Cools M, Grijp C, Neirinck J, Tavernier SJ, Schelstraete P, Van De Velde J, Morbée L, De Baere E, Bonroy C, van Bever Y, Bruggenwirth H, Vermont C, Hannema SE, De Rijke Y, Abdulhadi-Atwan M, Zangen D, Verdin H, Haerynck F. Spleen function is reduced in individuals with NR5A1 variants with or without a difference of sex development: a cross-sectional study. Eur J Endocrinol 2024; 190:34-43. [PMID: 38128121 DOI: 10.1093/ejendo/lvad174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE NR5A1 is a key regulator of sex differentiation and has been implicated in spleen development through transcription activation of TLX1. Concerns exist about hypo- or asplenism in individuals who have a difference of sex development (DSD) due to an NR5A1 disease-causing variant. We aimed to assess spleen anatomy and function in a clinical cohort of such individuals and in their asymptomatic family member carriers. DESIGN Cross-sectional assessment in 22 patients with a DSD or primary ovarian insufficiency and 5 asymptomatic carriers from 18 families, harboring 14 different NR5A1 variants. METHODS Spleen anatomy was assessed by ultrasound, spleen function by peripheral blood cell count, white blood cell differentiation, percentage of nonswitched memory B cells, specific pneumococcal antibody response, % pitted red blood cells, and Howell-Jolly bodies. RESULTS Patients and asymptomatic heterozygous individuals had significantly decreased nonswitched memory B cells compared to healthy controls, but higher than asplenic patients. Thrombocytosis and spleen hypoplasia were present in 50% of heterozygous individuals. Four out of 5 individuals homozygous for the previously described p.(Arg103Gln) variant had asplenia. CONCLUSIONS Individuals harboring a heterozygous NR5A1 variant that may cause DSD have a considerable risk for functional hyposplenism, irrespective of their gonadal phenotype. Splenic function should be assessed in these individuals, and if affected or unknown, prophylaxis is recommended to prevent invasive encapsulated bacterial infections. The splenic phenotype associated with NR5A1 variants is more severe in homozygous individuals and is, at least for the p.(Arg103Gln) variant, associated with asplenism.
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Affiliation(s)
- Martine Cools
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Celien Grijp
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Jana Neirinck
- Department of Diagnostic Science, Ghent University, Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Simon J Tavernier
- Department of Internal Medicine and Pediatrics, PID Research Lab, Ghent University, 9000 Ghent, Belgium
- Laboratory of Molecular Signal Transduction in Inflammation, Center for Inflammation Research, VIB, 9000 Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Petra Schelstraete
- Department of Internal Medicine and Pediatrics, Pediatric Pulmonology and Infectious Diseases, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
| | - Julie Van De Velde
- Department of Internal Medicine and Pediatrics, Pediatric Endocrinology Service, Ghent University, Ghent University Hospital, 9000 Ghent, Belgium
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Lieve Morbée
- Department of Radiology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Carolien Bonroy
- Department of Diagnostic Science, Ghent University, Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Yolande van Bever
- Department of Clinical Genetics, Erasmus MC, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Hennie Bruggenwirth
- Department of Clinical Genetics, Erasmus MC, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Clementien Vermont
- Department of Pediatric Infectious Diseases and Immunology, Erasmus Medical Center-Sophia Children's Hospital, 3015 GD Rotterdam, The Netherlands
| | - Sabine E Hannema
- Department of Pediatric Endocrinology, Erasmus Medical Center-Sophia Children's Hospital, 3015 GD Rotterdam, The Netherlands
- Department of Paediatric Endocrinology, Gastroenterology Endocrinology Metabolism, Reproduction and Development, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Yolanda De Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Center 3015 GD Rotterdam, The Netherlands
| | - Maha Abdulhadi-Atwan
- Department of Pediatrics, Pediatric Endocrinology Service, Palestine Red Crescent Society Hospital, PO Box 421, Hebron, Palestine
| | - David Zangen
- Division of Pediatric Endocrinology, Faculty of Medicine, Hadassah University Hospital, Hebrew University of Jerusalem, 91120 Jerusalem, Israel
| | - Hannah Verdin
- Center for Medical Genetics, Ghent University Hospital, Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Filomeen Haerynck
- Department of Internal Medicine and Pediatrics, PID Research Lab, Ghent University, 9000 Ghent, Belgium
- Department of Pediatric Pulmonology and Immunology, Centre for Primary Immune Deficiency, Jeffrey Modell Diagnostic and Research Centre for PID, Ghent University Hospital, 9000 Ghent, Belgium
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Yang Y, Liu D, He Z, Zhang X, Liu H, Li X, Ma H, Shi W. Specific Spleen-Accumulated NIR-II Fluorescent Probe for Imaging-Guided Splenic Operation. Adv Healthc Mater 2023; 12:e2300434. [PMID: 36975845 DOI: 10.1002/adhm.202300434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Spleen is a large immune organ in the body. Splenic operations such as splenectomy and intrasplenic injection are of paramount importance for immunological research and splenic diseases. Fluorescence imaging can vastly simplify these operations, but a specific spleen-targeting probe is still unavailable. Herein, the first specific spleen-accumulated fluorescent probe, VIX-S is reported, which fluoresces at 1064 nm and is highly stable. Systematic studies reveal the superior targeting and imaging performance of VIX-S for the spleen in both nude and haired mice. In vivo imaging indicates that the probe can image the morphology of spleen with a signal-background ratio of at least two-fold higher than that of the liver. Moreover, the application of VIX-S in imaging-guided splenic operation, including splenic injury and intrasplenic injection, is demonstrated, which may provide a practice tool for spleen research in the animal model.
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Affiliation(s)
- Yiqing Yang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- Key Laboratory of Chemical Biology of Hebei Province, College of Chemistry and Environmental Science, Hebei University, Baoding, 071002, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Diankai Liu
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Zixu He
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Xiaofan Zhang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Huihui Liu
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Xiaohua Li
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
| | - Huimin Ma
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Wen Shi
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Analytical Chemistry for Living Biosystems, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
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Abstract
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.
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Slater SJ, Lukies M, Kavnoudias H, Zia A, Lee R, Bosco JJ, Joseph T, Clements W. Immune function and the role of vaccination after splenic artery embolization for blunt splenic injury. Injury 2022; 53:112-115. [PMID: 34565618 DOI: 10.1016/j.injury.2021.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/08/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
The spleen is the most commonly injured solid organ following blunt abdominal trauma. Over recent decades, splenic artery embolization (SAE) has become the mainstay treatment for haemodynamically stable patients with high-grade blunt splenic trauma, with splenectomy the mainstay of treatment for unstable patients. Splenic function is complex but the spleen has an important role in immune function, particularly in protection against encapsulated bacteria. Established evidence suggests that following splenectomy immune function is impaired resulting in increased susceptibility to overwhelming post-splenectomy infection, however, immune function may be preserved following SAE. This review will discuss the current state of the literature on immune function following different treatments of blunt splenic injury, and the controversies surrounding what constitutes a quantitative test of splenic immune function.
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Affiliation(s)
- Samuel J Slater
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Matthew Lukies
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - Adil Zia
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Robin Lee
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Julian J Bosco
- Department of Respiratory medicine, Allergy, asthma and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia; Department of Surgery, Monash University Central Clinical School, Australia; National Trauma Research Institute, Monash University Central Clinical School, Melbourne, Australia.
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Wilson TM, Weber DG. Trauma splenectomy in a patient with previous total splenectomy. ANZ J Surg 2021; 92:1905-1906. [PMID: 34783425 DOI: 10.1111/ans.17371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Tamalee M Wilson
- State Major Trauma Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.,UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
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Tognarelli A, Faggioni L, Erba AP, Faviana P, Durante J, Manassero F, Selli C. Robotically assisted removal of pelvic splenosis fifty-six years after splenectomy: A case report. World J Clin Cases 2021; 9:2868-2873. [PMID: 33969071 PMCID: PMC8058664 DOI: 10.12998/wjcc.v9.i12.2868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/26/2020] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND ‘Splenosis’ is defined as the autotransplantation of splenic tissue following trauma or surgery, usually in the form of intraperitoneal nodules. The proliferation of imaging techniques has resulted in increased unexpected discoveries of splenosis nodules, and achieving a differential diagnosis can be challenging. Nuclear medicine studies have been playing an increasingly important role in this process, but the clinical significance of asymptomatic nodules remains uncertain.
CASE SUMMARY We present a case of pelvic splenosis in a 73-year-old man diagnosed 56 years after a splenectomy during a computed tomography (CT) follow-up for B-cell lymphoma, presenting intense contrast enhancement of an 18 mm nodule in the right recto-vesical space. 18F-fluorodeoxyglucose demonstrated weak metabolic activity. Since histological diagnosis was deemed necessary, the nodule was easily removed with robotically assisted laparoscopy, together with another 6 mm left a paracolic lesion. The latter was previously undiagnosed but retrospectively visible on the CT scan.
CONCLUSION In a patient requiring differential diagnosis of splenosis nodules from lymphoma recurrence, the robotic approach provided a safe en bloc removal with short hospitalization. The Da Vinci Xi robot was particularly helpful because its optics can be introduced from all ports, facilitating visualization and lysis of multiple intra-abdominal adhesions.
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Affiliation(s)
- Alessio Tognarelli
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Urology, University of Pisa, Pisa 56126, Italy
| | - Lorenzo Faggioni
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Diagnostic and Interventional Radiology, University of Pisa, Pisa 56126, Italy
| | - Anna Paola Erba
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Nuclear Medicine, University of Pisa, Pisa 56126, Italy, Pisa 56126, Italy
| | - Pinuccia Faviana
- Department of Surgical, Medical and Molecular Pathology and Critical Area, Section of Pathology, University of Pisa, Pisa 56126, Italy
| | - Jacopo Durante
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Urology, University of Pisa, Pisa 56126, Italy
| | - Francesca Manassero
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Urology, University of Pisa, Pisa 56126, Italy
| | - Cesare Selli
- Department of Translational Research and New Technologies in Medicine and Surgery, Section of Urology, University of Pisa, Pisa 56126, Italy
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