Eduovisual
Immune System
Asplenia: vaccination schedule and infection prevention
— Asplenia = absent splenic function, whether anatomic (surgical removal, congenital absence) or functional (sickle cell disease, celiac, advanced cirrhosis, lupus, lymphoma, radiation, splenic infarction, splenic artery embolization)
— Spleen filters encapsulated organisms and produces IgM memory B cells; loss creates lifelong risk of overwhelming post-splenectomy infection (OPSI), with mortality up to 50%
— Trauma splenectomy (motor vehicle crash, contact sports)
— Hematologic: ITP refractory to medical therapy, hereditary spherocytosis, lymphoma staging (historical)
— Sickle cell disease: functional asplenia by age 2–4 in HbSS
— Celiac disease (hyposplenism in up to one-third)
— Splenic artery embolization for trauma (partial → still treat as asplenic if >50% devascularized)
— Howell-Jolly bodies, Pappenheimer bodies, target cells, or thrombocytosis on peripheral smear
— History of left upper quadrant surgical scar without clear documentation
— Sepsis from Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis, Capnocytophaga canimorsus (dog bite), or severe Babesia/malaria
— Family medicine focus: identify asplenia at intake, document on problem list, ensure vaccines, antibiotic prophylaxis when indicated, MedicAlert bracelet, travel counseling
— Verify vaccine status at every preventive visit; gaps are common after trauma splenectomies done emergently
Board pearl: Howell-Jolly bodies on a routine CBC peripheral smear in an asymptomatic adult should prompt you to ask about prior splenectomy or screen for celiac disease — functional hyposplenism is an underrecognized celiac complication and an indication for the asplenia vaccine schedule.
— Prodrome of flu-like illness (fever, myalgias, vomiting) progressing within hours to septic shock, DIC, purpura fulminans, and Waterhouse-Friderichsen-like adrenal hemorrhage
— Mortality highest in first 24 hours; lifetime OPSI risk ~5% post-splenectomy, but case fatality 38–69%
— Risk is highest in the first 2 years post-splenectomy but persists indefinitely
— Date and indication for splenectomy (trauma vs hematologic vs oncologic)
— Vaccination dates: pneumococcal (PCV20 or PCV15+PPSV23), meningococcal ACWY and B, Hib, influenza, COVID-19
— Current antibiotic prophylaxis: agent, dose, adherence
— Animal exposures: dog/cat bites (Capnocytophaga), tick bites (Babesia, Ehrlichia)
— Travel: malaria-endemic regions confer disproportionate risk
— Prior infections since splenectomy
— Any fever ≥38°C (100.4°F) — treat as emergency
— Rigors, severe headache, neck stiffness, petechiae, or focal cellulitis after animal bite
— Hemodynamic symptoms: lightheadedness, oliguria
— Sickle cell patients: parents must recognize fever as emergency from infancy
— Congenital asplenia (often with heterotaxy/cardiac defects — Ivemark syndrome): suspect in neonate with complex CHD and Howell-Jolly bodies
Step 3 management: Every asplenic patient should leave the office with a standing prescription for an emergency self-start antibiotic (amoxicillin-clavulanate 875 mg or levofloxacin if penicillin-allergic) to take immediately upon fever onset, followed by ED evaluation within hours. Document this counseling explicitly — failure to provide it is a recurrent malpractice and Step 3 patient-safety scenario. Reinforce the script at annual visits and confirm the patient has not let it expire.
— Left subcostal or midline laparotomy scar; laparoscopic port sites
— Absent splenic dullness to percussion (Castell's sign negative)
— In sickle cell: autoinfarcted spleen — non-palpable by adolescence; look for jaundice, scleral icterus, leg ulcers
— Temperature >38°C or <36°C, HR >90, RR >20, altered mentation
— Petechiae and purpura fulminans: pathognomonic for meningococcemia or pneumococcal DIC in this population
— Cold, mottled extremities; delayed capillary refill >3 sec
— Meningismus may be subtle or absent despite bacteremia
— Hypotension is late — do not wait for it
— qSOFA ≥2 (RR ≥22, AMS, SBP ≤100) → high mortality
— Lactate >2 mmol/L → tissue hypoperfusion
— Shock index (HR/SBP) >1.0 → impending decompensation
— Mean arterial pressure goal ≥65 mm Hg after fluid resuscitation
— Recent dog bite or lick (often trivial wound) + sepsis + peripheral gangrene/symmetric purpura
— Gram stain: fusiform gram-negative rods
— Hemolytic anemia, hemoglobinuria, jaundice, splenomegaly (if residual splenic tissue) — parasitemia can exceed 10%, may require exchange transfusion
CCS pearl: In the simulated case of an asplenic patient with fever, your first three orders should be: (1) blood cultures ×2, (2) empiric IV ceftriaxone 2 g (add vancomycin if meningitis suspected; doxycycline if tick exposure), (3) IV crystalloid bolus 30 mL/kg. Do not delay antibiotics for imaging or LP — every hour of delay increases mortality. Lactate, CBC with diff, and peripheral smear (look for intraerythrocytic parasites) round out the initial bundle.
— Peripheral blood smear is the cornerstone office test: Howell-Jolly bodies (nuclear remnants), Pappenheimer bodies (iron inclusions), target cells, acanthocytes, thrombocytosis (often 600–1000 k post-splenectomy, usually benign)
— Howell-Jolly body count by flow cytometry quantifies splenic function in research/specialty settings
— Pitted erythrocyte percentage >4% indicates hyposplenism
— Abdominal ultrasound confirms absence or small accessory spleen (splenosis common after trauma — 10–20%)
— CT abdomen for surgical history confirmation or to identify accessory splenic tissue causing recurrent ITP/spherocytosis
— Heat-damaged RBC scan or technetium-99m sulfur colloid scan: gold standard for functional splenic mass
— CBC with differential, reticulocyte count
— Comprehensive metabolic panel
— HIV, hepatitis B surface Ag/Ab/core, hepatitis C — vaccine response and infection screening
— Celiac serology (tTG-IgA + total IgA) if hyposplenism is incidental
— Blood cultures ×2 from separate sites before antibiotics (but do not delay antibiotics)
— CBC, CMP, lactate, coags (DIC panel: PT/INR, PTT, fibrinogen, D-dimer)
— Urinalysis and urine culture
— Peripheral smear: look for intraleukocytic diplococci (pneumococcal sepsis sign), Babesia, malaria
— Chest X-ray
— Lumbar puncture if meningismus or altered mentation (after head CT if focal signs/papilledema)
Board pearl: Intraleukocytic gram-positive diplococci on a routine buffy coat smear of an asplenic patient with sepsis is essentially pathognomonic for pneumococcal bacteremia — a finding rarely seen in immunocompetent hosts because their spleens clear the organism before this level of bacteremia develops. This is a classic Step 3 image-stem question.
— Pneumococcal antibody titers to serotype-specific polysaccharides 4–8 weeks post-PPSV23 — used in immunology referral if recurrent encapsulated infections despite vaccination
— Meningococcal serum bactericidal antibody (SBA) titers: not routine, used in research
— Hemoglobin electrophoresis (sickle cell, thalassemia)
— Celiac panel (tTG-IgA, EMA, total IgA); endoscopy with duodenal biopsy if positive
— ANA, anti-dsDNA, complement (SLE)
— Liver disease evaluation: ultrasound with elastography, MELD score
— Bone marrow biopsy if lymphoma suspected
— Blood culture speciation (24–48 h): S. pneumoniae, N. meningitidis, H. influenzae, Capnocytophaga
— PCR for meningococcus and pneumococcus if cultures negative after antibiotic pretreatment
— Babesia thick/thin smear and PCR; Ehrlichia/Anaplasma PCR if tick exposure
— Malaria thick/thin smear with parasitemia quantification
— Repeat lactate at 2–4 h to confirm clearance
— Procalcitonin (supportive but not for initial decision-making)
— Echocardiogram if persistent shock or new murmur (endocarditis ~3× more likely)
— Adrenal axis: random cortisol if refractory shock (Waterhouse-Friderichsen)
— Heat-damaged RBC scintigraphy after partial splenectomy or splenic embolization clarifies whether to continue full asplenia protocol
Key distinction: Anatomic asplenia has zero residual function and mandates lifelong protocol. Functional asplenia (sickle cell, celiac, splenic embolization) may be partial — but for vaccination and prophylaxis purposes, treat all as fully asplenic. Step 3 will not reward you for dose-reducing protection based on residual function.
— Highest risk: children <5 years, first 2 years post-splenectomy, hematologic/oncologic indication, prior OPSI
— Moderate risk: adults with trauma splenectomy >2 years out, well-vaccinated, adherent to prophylaxis
— Lifetime OPSI risk remains elevated even decades later — never discontinue surveillance
— Elective splenectomy: vaccinate ≥2 weeks before surgery (optimal immune response)
— Emergent/trauma splenectomy: vaccinate ≥14 days after surgery (improves immune response vs immediate); if patient unlikely to return, vaccinate before discharge
— Avoid vaccinating during active chemotherapy; wait ≥3 months after chemo, ≥6 months after rituximab, ≥2 weeks after high-dose steroids
— Pneumococcal: PCV20 alone, OR PCV15 followed by PPSV23 ≥8 weeks later (≥1 year preferred in immunocompetent, but ≥8 weeks acceptable in asplenia)
— Meningococcal ACWY: 2-dose primary series 8 weeks apart, booster every 5 years lifelong
— Meningococcal B: 2-dose Bexsero (0, ≥1 month) or 3-dose Trumenba (0, 1–2, 6 months), booster 1 year then every 2–3 years
— Haemophilus influenzae type b (Hib): single dose if not previously vaccinated
— Influenza: annually (inactivated)
— COVID-19: per current ACIP schedule
— Tdap, HPV, zoster (≥50), RSV (≥60), hepatitis B (3-dose), MMR/varicella if non-immune (live vaccines NOT contraindicated in asplenia alone — only contraindicated if also immunosuppressed)
Step 3 management: When in doubt on timing post-splenectomy, the answer is 14 days post-op. When in doubt on pneumococcal product, PCV20 alone is the simplest current ACIP-preferred option for asplenic adults — eliminates the PCV15→PPSV23 sequencing question.
— Children: penicillin V 125 mg PO BID (<5 years) or 250 mg BID (≥5 years) until at least age 5 AND ≥1 year post-splenectomy; many continue lifelong in sickle cell
— Adults: prophylaxis recommended for at least 1–2 years post-splenectomy, lifelong if prior OPSI, hematologic malignancy, or immunocompromise
— Penicillin V 250–500 mg PO BID OR amoxicillin 500 mg PO daily
— Penicillin-allergic: macrolide (azithromycin) or doxycycline; avoid in pregnancy
— Every asplenic patient should carry a single course
— First-line: amoxicillin-clavulanate 875/125 mg BID ×3 days — start at first fever, then immediately seek ED care
— Alternative (penicillin allergy): levofloxacin 750 mg or moxifloxacin 400 mg daily
— Counsel: this does not replace ED evaluation
— Ceftriaxone 2 g IV q24h (q12h if meningitis suspected) — covers pneumococcus, meningococcus, Hib
— Add vancomycin 15–20 mg/kg IV q8–12h if meningitis, severe sepsis, or pneumococcal resistance concern
— Add doxycycline 100 mg IV/PO BID if tick exposure (Babesia, Ehrlichia, Anaplasma)
— Add atovaquone-azithromycin or clindamycin-quinine for confirmed babesiosis; exchange transfusion if parasitemia >10% or severe hemolysis
— Capnocytophaga: ceftriaxone or pip-tazo; ampicillin-sulbactam covers bite wounds broadly
— IV fluids, vasopressors (norepinephrine first-line), stress-dose steroids only if refractory shock
— Activated protein C is no longer recommended
Board pearl: A febrile asplenic patient presenting to the ED with already-taken amoxicillin-clavulanate at home is not "treated" — they require full sepsis workup and IV antibiotics. The home dose buys time, not resolution.
— Bracelet/necklace stating "asplenic" or "no spleen"
— Wallet card with vaccine dates, prophylaxis regimen, emergency antibiotic
— Problem list flag in the EHR; visible on every encounter
— Partial splenectomy or splenic artery embolization preferred over total splenectomy when oncologically/hematologically acceptable — preserves some immune function but still warrants full asplenia protocol if >50% devascularized
— Splenic autotransplantation: limited evidence of functional benefit; do not rely on it
— Pre-travel consultation ≥4–6 weeks before departure
— Malaria chemoprophylaxis is mandatory for any endemic area — atovaquone-proguanil, doxycycline, or mefloquine (counsel: malaria in asplenia is rapidly fatal)
— Updated meningococcal vaccine for Hajj, sub-Saharan Africa meningitis belt
— Typhoid (inactivated injectable Vi preferred over oral Ty21a in immunocompromised)
— Yellow fever: live vaccine, not contraindicated in isolated asplenia (safe), but contraindicated if concurrent immunosuppression
— Avoid tick-endemic activities or use rigorous DEET/permethrin; daily tick checks
— Any animal bite/scratch: immediate amox-clav prophylaxis ×5 days, even if wound appears trivial — Capnocytophaga can be lethal
— Dental procedures: routine antibiotic prophylaxis is not recommended solely for asplenia (per AHA), but maintain meticulous oral hygiene
— Update meningococcal and pneumococcal vaccines pre-conception; Tdap each pregnancy
CCS pearl: On a CCS case with an asplenic patient planning international travel, order travel medicine consult, malaria chemoprophylaxis prescription, updated MenACWY, and a written fever action plan in addition to indication-specific vaccines. Forgetting malaria prophylaxis is a frequent point-loss.
— Immunosenescence further reduces vaccine response — ensure complete and updated schedule
— Higher baseline pneumonia and meningitis mortality
— Add age-appropriate vaccines: RSV (≥60), zoster recombinant (≥50), high-dose or adjuvanted influenza (≥65), pneumococcal regardless of asplenia status already required
— Polypharmacy: avoid drug interactions with prophylactic antibiotics (e.g., warfarin–TMP-SMX, statin–macrolide)
— Dose adjustments: levofloxacin, TMP-SMX, ceftriaxone (usually no renal adjustment) — verify with eGFR
— Penicillin V prophylaxis generally safe across CKD stages
— Patients on dialysis: schedule vaccines around dialysis day (typically after session)
— Hepatitis B series: use higher-dose schedule (Heplisav-B preferred — 2-dose, more immunogenic in CKD)
— Cirrhotic patients have functional hyposplenism + SBP risk → already on prophylaxis (norfloxacin/ciprofloxacin for SBP) covers some encapsulated organisms
— Avoid hepatotoxic prophylactic agents; minimize acetaminophen during febrile episodes
— Vaccine response is reduced — check titers when feasible; double-dose hepatitis B (Heplisav-B preferred)
— MELD ≥15: consider transplant evaluation; pre-transplant vaccines should be updated
— Live vaccines (MMR, varicella, zoster live, yellow fever) contraindicated
— Recombinant zoster (Shingrix) is non-live and preferred
— Prophylactic antibiotics typically lifelong
— Higher empiric antibiotic threshold for febrile illness
Key distinction: Asplenia alone does not contraindicate live vaccines — concurrent immunosuppression does. A trauma splenectomy patient on no other meds can safely receive MMR, varicella, and live zoster (though Shingrix is preferred for efficacy). Step 3 frequently tests this nuance.
— Pregnancy is a relative immunocompromised state — OPSI risk may rise
— Continue penicillin V prophylaxis throughout pregnancy (category B)
— Avoid doxycycline, fluoroquinolones, TMP-SMX (1st trimester and near term)
— Inactivated influenza in any trimester; Tdap at 27–36 weeks; RSV maternal vaccine (Abrysvo) 32–36 weeks
— Pneumococcal and meningococcal vaccines: safe in pregnancy if indicated and not previously completed
— Live vaccines (MMR, varicella) deferred until postpartum
— Heterotaxy syndromes (Ivemark/right or left atrial isomerism) — screen with smear for Howell-Jolly bodies and abdominal ultrasound
— Begin penicillin V prophylaxis at birth/diagnosis
— Follow ACIP infant pneumococcal series (PCV15 or PCV20) plus supplemental PPSV23 at age ≥2 years
— MenACWY starting at 2 months (MenQuadfi or Menveo), MenB at ≥10 years or earlier if specialist directs
— Hib per routine schedule plus additional dose if splenectomy at older age
— Penicillin V prophylaxis from age 2 months to at least age 5; longer if prior pneumococcal sepsis or splenectomy
— Full asplenia vaccine schedule
— Hydroxyurea reduces infection rate indirectly
— Fever ≥38.5°C: immediate ED evaluation, blood cultures, empiric ceftriaxone — no exceptions
— Defer splenectomy until age ≥5 if possible to reduce OPSI risk
— Complete vaccine series ≥2 weeks pre-op
Board pearl: A 3-year-old with sickle cell and fever to 39°C is the prototype "do not delay" Step 3 stem — order blood cultures, give ceftriaxone within 60 minutes, admit. Sending home on outpatient antibiotics is the wrong answer regardless of how well the child appears.
— Mortality 38–69% even with optimal care
— Pathogens: S. pneumoniae (50–90%), H. influenzae, N. meningitidis, Capnocytophaga canimorsus, E. coli, group A Strep, Bordetella holmesii
— DIC, purpura fulminans, bilateral adrenal hemorrhage (Waterhouse-Friderichsen), multiorgan failure
— Babesiosis: severe hemolysis, parasitemia >10%, may need exchange transfusion; coinfection with Lyme common in endemic areas
— Malaria: fulminant P. falciparum with rapid hyperparasitemia
— Ehrlichiosis/Anaplasmosis: more severe in asplenia
— Post-splenectomy reactive thrombocytosis (often >1,000,000/μL) — usually benign but increased risk of portal/mesenteric vein thrombosis, especially in myeloproliferative disorders
— Consider aspirin if platelets >1,000,000 with additional risk factors
— Pulmonary hypertension risk elevated long-term (especially in thalassemia, hereditary stomatocytosis — splenectomy contraindicated in stomatocytosis)
— Local reactions common; serious adverse events rare
— Document vaccine reactions to guide future schedules
— Modestly increased cardiovascular mortality post-splenectomy in observational cohorts
— Maintain standard CV prevention (statin, BP, glycemic control)
— Anxiety around fever; counsel that vigilance + rapid response = excellent outcomes
— Avoid contact sports temporarily until cleared if recent splenectomy (irrelevant if no spleen, but post-op recovery considerations)
Key distinction: Persistent thrombocytosis post-splenectomy is expected and does not require workup or treatment in isolation. Workup if platelets >1,000,000 with thrombosis, or to evaluate for an underlying myeloproliferative disorder (JAK2, BCR-ABL) when the splenectomy indication doesn't explain the count.
— Any fever ≥38°C in an asplenic patient → ED evaluation, even if appears well
— Tachycardia, hypotension, altered mentation, petechiae → resuscitation bay
— All confirmed bacteremia → admission for IV antibiotics minimum 7–14 days
— Septic shock (vasopressor requirement, lactate >4)
— DIC, purpura fulminans
— Respiratory failure or ARDS
— Babesia parasitemia >10%, severe hemolysis, end-organ damage
— Meningitis with altered mentation, seizures, or elevated ICP
— Infectious disease: confirmed OPSI, recurrent infection, atypical pathogen, suspected vaccine failure (titers)
— Hematology: underlying disorder workup (sickle cell, thalassemia, lymphoma, myeloproliferative), persistent extreme thrombocytosis with thrombosis
— Immunology: poor vaccine response, recurrent encapsulated infections despite vaccination — consider concurrent humoral immunodeficiency (CVID, IgG subclass deficiency)
— General surgery: accessory spleen identification, splenosis evaluation
— Trauma splenectomy → hospital discharge: ensure all vaccines initiated, prophylaxis prescribed, emergency antibiotic provided, PCP follow-up within 1–2 weeks
— Discharge after OPSI: full vaccine reassessment (response may be blunted)
— Transfer between facilities: hand-off documentation must include asplenia status
— Recurrent infections despite adherence → switch prophylactic agent and refer immunology
— Adherence challenges → engage care management, pharmacist, MedicAlert
Step 3 management: A well-appearing asplenic adult with isolated fever 38.2°C, normal vitals, normal labs still gets admitted for 24–48 hour observation with IV antibiotics until blood cultures return negative. Outpatient management is not the correct answer on the exam even if it sometimes occurs in practice.
— Although asplenia raises encapsulated organism risk, asplenic patients still get the full spectrum of infections — evaluate broadly
— Complement deficiencies (C5–C9, properdin): recurrent meningococcal disease especially with non-groupable serotypes; check CH50, AH50
— Humoral immunodeficiencies: CVID, X-linked agammaglobulinemia, IgG subclass deficiency, specific antibody deficiency — recurrent sinopulmonary infections with encapsulated organisms
— HIV/AIDS: pneumococcal disease risk markedly elevated
— Multiple myeloma and CLL: functional hypogammaglobulinemia
— Nephrotic syndrome: urinary loss of immunoglobulins, increased pneumococcal infection (especially peritonitis in children)
— Sickle cell disease: confirm with hemoglobin electrophoresis
— Celiac disease: tTG-IgA — vaccinate per asplenia protocol if hyposplenism documented
— Advanced cirrhosis with splenic congestion paradoxically reduces function despite splenomegaly
— Lupus, rheumatoid arthritis with chronic inflammation
— Bone marrow/stem cell transplant recipients
— Asplenia/hyposplenism (most common)
— Severe megaloblastic anemia (B12/folate deficiency) — corrects with treatment
— Myelodysplastic syndrome
— Newborn period (transient)
Board pearl: A young adult with recurrent Neisseria meningitidis infections (especially serogroups Y or W or non-typeable) — even if vaccinated and not asplenic — needs terminal complement deficiency workup (CH50, AH50). Conversely, a single severe pneumococcal sepsis episode should prompt asplenia/HIV/myeloma evaluation.
— Viral sepsis-like syndromes: influenza, COVID-19, dengue, hantavirus — treat empirically as bacterial until cultures clear
— Tick-borne illness: babesiosis, ehrlichiosis, RMSF, Lyme — overlap with bacterial sepsis
— Drug reaction with eosinophilia and systemic symptoms (DRESS): fever + rash + systemic involvement
— Adrenal crisis: hypotension, hyponatremia, hyperkalemia; consider if on chronic steroids
— Thrombotic microangiopathy (TTP/HUS): fever, AKI, hemolysis, thrombocytopenia — but in asplenia, baseline thrombocytosis may mask thrombocytopenia
— Iron deficiency anemia (reactive thrombocytosis)
— Inflammation/malignancy
— Essential thrombocythemia (JAK2 mutation) — distinguish from post-splenectomy reactive
— If a patient labeled asplenic has palpable spleen → accessory spleen, splenosis (traumatic implantation), or misdiagnosis
— Confirm with technetium scan
— Meningococcemia, pneumococcal sepsis with DIC, Capnocytophaga sepsis
— Protein C/S deficiency (especially congenital homozygous in neonate)
— Warfarin-induced skin necrosis
— Heparin-induced thrombocytopenia
— Postoperative atelectasis
— Subphrenic abscess
— Pancreatic tail injury with pancreatitis
— Pulmonary embolism
— Drug fever
Key distinction: Fever within the first 7 postoperative days after splenectomy is often non-infectious (atelectasis, drug fever, DVT/PE) — but in asplenic patients you still pan-culture and start empiric antibiotics while sorting it out. Threshold is lower than for non-asplenic surgical patients.
— PPSV23: if PCV15+PPSV23 strategy used, second PPSV23 ≥5 years after first (current ACIP no longer routinely recommends third PPSV23; check latest)
— MenACWY: every 5 years lifelong
— MenB: booster 1 year after primary, then every 2–3 years if continued risk
— Influenza: annually
— COVID-19: per current schedule
— Tdap: every 10 years (Tdap once, then Td)
— Recombinant zoster (Shingrix) at age ≥50
— RSV at age ≥60 (single dose currently)
— Children: through age 5 minimum, often longer in sickle cell
— Adults: ≥1–2 years post-splenectomy minimum
— Lifelong if: prior OPSI, hematologic malignancy, immunocompromise, poor vaccine response
— Fever action plan: take standby antibiotic immediately, go to ED
— Animal bite plan: immediate amox-clav, medical evaluation
— Travel planning ≥4–6 weeks in advance
— MedicAlert use
— Carry written summary of vaccines and prophylaxis
— Asplenia registries in some health systems improve vaccine uptake (only ~50% of asplenic patients are fully vaccinated)
— Annual nurse-led "asplenia review" visit captures gaps
— EHR best-practice alerts at every encounter
— Insurance coverage: most vaccines covered under ACA preventive services without cost-sharing
Step 3 management: At every annual preventive visit for an asplenic patient, run through a 5-point checklist: (1) vaccines updated, (2) prophylactic antibiotic adherence, (3) emergency antibiotic on hand and unexpired, (4) MedicAlert worn, (5) travel/animal exposure plans reviewed. Document the checklist.
— 2 weeks post-splenectomy: wound check, confirm vaccines initiated/scheduled, prescribe standby antibiotic, MedicAlert ordered
— 6 weeks: confirm vaccine completion, baseline CBC (document thrombocytosis), reinforce education
— 3 months: review adherence; consider pneumococcal titers in selected patients
— Annually thereafter: comprehensive asplenia review (see chunk 15 checklist)
— CBC every 6–12 months in first 2 years (track thrombocytosis trend)
— Lipid, glucose, BP — standard preventive care
— Repeat celiac serology if symptoms recur (in celiac-associated hyposplenism)
— Hemoglobin electrophoresis once for confirmation in sickle cell (lifelong diagnosis)
— Pneumococcal serotype titers 4–8 weeks post-PPSV23 in patients with recurrent infection despite vaccination
— Refer to immunology if <70% of serotypes achieve protective levels
— Fever is an emergency, even if patient feels well
— Animal bites need same-day antibiotics and medical evaluation
— Travel planning is mandatory, not optional
— Carry vaccine record digitally and on paper
— Family members should know the fever action plan
— No specific activity restriction once recovered from splenectomy
— Contact sports allowed (no spleen to rupture)
— Tobacco cessation critical (synergistic pneumonia risk)
— Alcohol moderation (further impairs immune function)
— Address health-related anxiety; provide structured action plans to reduce uncertainty
— Support groups for sickle cell, thalassemia patients
CCS pearl: Schedule the annual asplenia review as a recurring order in the CCS interface — this is a value-based-care behavior the exam rewards. Forgetting follow-up scheduling on outpatient cases loses points even when acute management is correct.
— Elective splenectomy consent must explicitly discuss lifelong OPSI risk (~5% lifetime incidence, 38–69% mortality), vaccine requirements, prophylactic antibiotics, and emergency action plans
— Document discussion in the chart; failure is a recurrent malpractice issue
— Patient may be unable to consent — surgery proceeds under emergency doctrine
— Post-discharge vaccine and education gap is the single biggest patient safety failure in this population — only ~50% of trauma splenectomy patients are fully vaccinated at 1 year
— Trauma surgery–to–primary care handoff must include written asplenia protocol and vaccine plan
— EHR problem list must include "asplenia"; alerts should fire at any encounter
— Medication reconciliation: confirm prophylactic antibiotic and emergency antibiotic at every visit
— Discharge after OPSI hospitalization: ensure follow-up within 1 week, recheck immunization status
— Neisseria meningitidis and Haemophilus influenzae invasive disease: reportable to public health
— Close contacts of meningococcal cases need post-exposure prophylaxis (rifampin, ciprofloxacin, or ceftriaxone)
— Family education and access barriers — engage social work and care management
— School notification for fever protocols
— Use motivational interviewing; emphasize life-threatening nature of OPSI
— Document refusal and ongoing re-offer
Board pearl: A frequent Step 3 ethics/safety stem: a trauma splenectomy patient returns 2 years later with no vaccines. The right answer is shared responsibility — initiate vaccines now, document the gap, and implement an EHR flag — not blame. The system, not the patient, failed.
— Pneumococcal (PCV20 or PCV15+PPSV23)
— Meningococcal ACWY (boost q5y) and MenB
— Hib (single dose)
— Influenza annually, COVID-19 per ACIP
Key distinction: PCV20 is preferred single-product strategy for asplenic adults; the older PCV13+PPSV23 schedule has been replaced. Always confirm current ACIP — the schedule evolves yearly.
— 25-year-old, MVA splenectomy 10 days ago, ready for discharge
— Question: when to vaccinate?
— Answer: vaccinate now (≥14 days post-op preferred but acceptable before discharge if follow-up uncertain) with PCV20 + MenACWY + MenB + Hib + influenza
— Asymptomatic adult, routine CBC shows Howell-Jolly bodies
— Question: next step?
— Answer: celiac serology (tTG-IgA + total IgA); evaluate for hyposplenism causes; if confirmed, full asplenia vaccine schedule
— Asplenic patient, dog lick on hand 3 days ago, now febrile, hypotensive, with peripheral gangrene
— Question: pathogen and treatment?
— Answer: Capnocytophaga canimorsus; IV ceftriaxone or pip-tazo, aggressive resuscitation, ICU
— Asplenic patient planning trip to sub-Saharan Africa
— Question: most important pre-travel intervention?
— Answer: malaria chemoprophylaxis (atovaquone-proguanil), MenACWY booster, written fever plan
— 3-year-old HbSS, fever 39°C, looks well
— Question: management?
— Answer: blood cultures, IV ceftriaxone within 60 minutes, admit
— Asplenic? — not necessarily; if not, think terminal complement deficiency (CH50, AH50)
— Hereditary spherocytosis, planned splenectomy in 6 weeks
— Question: vaccine timing?
— Answer: at least 2 weeks pre-op
— Trauma splenectomy 2 years ago, no PCP follow-up, presents for new patient visit
— Question: best action?
— Answer: review and update vaccines, prescribe prophylactic and standby antibiotics, MedicAlert, flag chart
Board pearl: When the stem mentions "Howell-Jolly bodies" in any context, your differential collapses to functional or anatomic asplenia — and the next best step is almost always either celiac screening (if asymptomatic) or full asplenia preventive bundle.
Asplenia — whether anatomic or functional — demands lifelong layered protection: vaccines against encapsulated organisms (pneumococcal, meningococcal ACWY+B, Hib, influenza, COVID-19) timed correctly around surgery, daily antibiotic prophylaxis in high-risk patients, an emergency standby antibiotic for first fever, and a structured fever-action plan, because OPSI carries 38–69% mortality despite optimal care.
Step 3 management: The single most testable behavior across all asplenia stems is proactive, system-level prevention — recognize the diagnosis on the problem list, run the checklist, close the gaps, and document. The exam rewards the family/preventive medicine physician who prevents OPSI rather than the one who only knows how to treat it.