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Prepared by.... Patcharaporn Wongkaewpothong,
M.D.
Janya Ananpiboonsri, M.D.
Thanyawee Puthanakit, M.D.
Virat Sirisanthana, M.D.
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| Patient: A 15-year-old girl
with beta-thalassemia major s/p splenectomy |
| CC: High-grade fever 6 hours
prior to admission |
Present Illness:
| 6 hr PTA: |
She developed a sudden onset of high fever,
headache and malaise. She had one episode of non mucous bloody diarrhea
and non bilous vomitting. |
Past Medical History:
> She had underlying beta thalassemia major. She had splenectomy when
she was 4 year old..
> No prophylactic antibiotics and pneumococcal immunization.
> She received blood transfusion every month with regular iron chelation
therapy.
> She has had 3 episodes of pneumonia that required hospitalization after
the splenectomy. |
Physical examination:
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GA: A girl with normal consciousness, febrile
V/S: BT 39.2 C, PR
130/min, BP 120/50 mmHg, RR 36/min.
BW: 32 kg (< 3rd percentile)
HEENT: mild pale conjunctivae, mild
icteric sclerae, no injected pharynx, tympanic membrane intact
LN: not palpable
Heart: regular rhythm, tachycardia, SEM
gr.3/6 at apex
Lungs: clear, no adventitious sound
Abdomen: soft, no guarding, liver 8
cm below RCM
Ext: no edema, no skin rash, capillary refill < 2 seconds
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Question 1: What is the diagnosis?
Diagnosis: Septicemia in asplenic
patient
Discussion:
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>
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Asplenic patients have
increased risk for overwhelming, life-threatening infections, most
commonly due to S.pneumoniae (50-90%), H.influenza,
N.meningitidis, Samonella spp. |
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>
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The level of risk appears
to correlate inversely with the amount of time a patient has had
a functioning spleen. Overall, approximately 5% of children whose
spleen are removed before the age of 4 years have significant infections,
with a mortality rate of 30% to 60%. |
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>
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Risk of infection is greatest
in the year after splenectomy (regardless of age) and continues
to be significant in the next 7 to 10 years, after which
risk is low but never as low as for patients with normal splenic
function. |
Pathogenesis
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>
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The central role of the
spleen are (1) mechanical clearance of antigen and foreign material,
(2) synthesis of factors such as tuftsin, which enhance phagocytosis,
and (3) coordination of interactions of the T-lymphocyte and B-lymphocyte
response to antigens. |
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>
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The encapsulated organisms
require antibody and complement for opsonization and clearance.
However, in the absence of preformed antibody, the spleen is critical
in clearing of the blood stream. |
Clinical manifestations
Characteristics of overwhelming postsplenectomy sepsis include the sudden
onset of fever and chills, vomiting and headache. The illness rapidly
progresses to hypotensive shock and is commonly accompanied by disseminated
intravascular coagulation
Question 2: What is the proper management?
Management of febrile illness in asplenic patient should include:
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Careful clinical evaluation |
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Investigations (including hemoculture) |
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Empirical antibiotic |
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| Progression of the case Continue...........
Next page |