My Journey With Asplenia...So Far
Submitted by Elaine S. Puricelli RN, BSN
Tags: Asplenia blood Infection prevention vaccine
Of all the illnesses, flu episodes and assorted “routine” surgeries that I could expect in a lifetime the occasion on which I had a splenectomy was not on my lifetime radar. My splenectomy suggested as a possible outcome, (of another type of surgery), and fortunately not a loss of an organ by trauma, as is the case with many splenectomies. Though I accepted the news of the removal of my spleen as a potential consequence of a distal pancreatectomy, the news came as a surprise when told to me by one of the two surgeons, the day after surgery. I feel fortunate that the splenectomy was not a consequence of any sort of accident, but the news of the loss of my spleen was upsetting on the day after surgery nonetheless. This essay is not written to malign my surgeons, as the two very competent and compassionate surgeons were equally aware of how disappointed I would be once the news was delivered. I knew the outcome was a possibility as per the verbiage on the operative consent form and with pre-operative discussions.
My initial concern once advised of my surgical loss of the spleen was for my job as a registered nurse. I remember thinking how I would have to have lifetime awareness of my working environment as far as infection control and pristine hand washing technique. I paid strict notice to routine masking practices (unless wearing an N-95 mask and/or a respirator and other PPE), with masking as required, for patients with flu and other respiratory illnesses and the need for wearing a mask when dealing with patients with infectious disease concerns in which a respiratory risk was apparent, all while performing my nursing duties in a humane and competent fashion. I had to be more alert to my own health status when it came to my personal risk of illness with regards to infectious disease exposure.
My post-splenectomy status is known as anatomic asplenia versus a dysfunctional type of condition of the spleen – my spleen was surgically removed, hence, anatomic asplenia. In addition to my awareness of infection control standards and hand washing consistency, I also embarked on a self-imposed mission to learn all that I could about my status as it will be lifelong unless spleen transplants become a more commonplace option for asplenics. I understand that at present, spleen transplants are not abundant in the medical/surgical landscape. I have read where multi-organ transplants have involved a spleen transplant as well, but for me, a singular organ transplant would be appropriate, if possible, in the future. Anatomic asplenia simply means there is no spleen present in the body habitus. A dysfunctional condition of the spleen is not addressed in this essay because dysfunctional conditions suggest the spleen is still anatomically intact, though impaired or malfunctioning in some way.
As a new asplenic I was advised that typically one should prepare one’s immune system prior to surgery by receiving vaccinations that will become commonplace, in a 5-year cycle (with the exception of H. Influenza B vaccination), as one goes through life as an asplenic. These vaccines are at first, H. Influenza B, pneumonia vaccine, and two different type of meningitis vaccines, vaccines that will cover meningitis strains A, C, Y,W and a separate meningitis vaccine to cover meningitis B strains. With the exception of H. Influenza B, pneumonia and both meningitis vaccines will be mandatory every 5 years of one’s life post-splenectomy. An annual flu vaccine is recommended as well. Be aware that the 5-year cycle vaccine schedule could change in the future as dictated by the medical community and/or CDC guidelines. I am advised by primary care, on the flu vaccine addition.
With this present year’s vaccine cycle, I had an occasion to visit an immunologist as this was my second 5-year cycle of vaccines. I had taken a measles, mumps and rubella titer prior to seeing the specialist for my vaccine assessment just as an aside, and the “MMR” vaccine is not one of the mandatory vaccines for asplenics, but it was situational in my case as there was concern in my workplace about measles outbreaks, amongst the general population. I received a measles, mumps, rubella vaccine a couple of months prior to starting my predicted 5-year vaccine cycle and just to have my vaccine information current, I looked up the date of my most recent tetanus vaccination, though it is not a required post-splenectomy vaccine. I just wanted a full profile of my vaccine history to present to the immunologist upon my first office visit. The medical specialist whom is now my resource for my asplenic state is a hematologist, not an immunologist. However my first and only meeting with immunology was very informative! I knew to expect to have blood drawn and sent away for titers, but the discussion with the immunologist proved enlightening to me. In my reading post-op about splenectomy, I had taken note of the most feared and serious organism that could befall a person such as myself; I knew that an encapsulated virus could be the most life-threatening condition to encounter. An example is the Novel Coronavirus, or COVID-19, that continues to be present in mutations, in present day. It is known by me that viruses routinely mutate in order to adapt to their physiologic environments. The seasonal flu is a great example of a virus that returns each year and one in which the population is commonly vaccinated. The arrival so soon into my life as an asplenic, of Covid (Omicron variant is my guess) sent me from diagnosis to treatment in the matter of 2 days. I was sent to an infusion center, by primary care’s directive, to receive a monoclonal antibody infusion. The actual infusion was far less benign than what my imagination led me to believe. The monoclonal antibody infusion was an hour-long infusion, into one venous infusion site only, followed by a saline infusion quantity following the antibody infusion. A 2-to- 3 hour endeavor with very kind and skillful infusion nurses. I know that each mutation of Covid could present another infection at any time, so avoidance of those with Covid exposure, vaccination (if recommended by one’s provider who knows about the asplenic state), adherence to mask mandates and extra attention when washing hands is paramount with the Covid threat. I will never take the Covid threat, nor any other type of encapsulated virus threat lightly or with a cavalier attitude. Encapsulated virus organism can be potentially fatal to asplenics at any life stage.
One of the valuable pieces of information I received from the immunologist was a brief discussion on why asplenics NEED a 5-year vaccine cycle. There will not typically be routine titer testing unless medical science changes a long-held asplenia regimen in the future: It is expected that the asplenic will keep precise records of names and dates administered of vaccines received with each 5-year cycle. In my case, I was able to advise the immunologist that I had been recently vaccinated against, “MMR,” and that my tetanus vaccination was within 5 years of the visit with the immunologist. I knew from memory, that I had received an H. Influenza B vaccine in the year of my splenectomy and was advised at the time of that vaccine, that the H. Influenza B was not required as a repeat vaccination with the 5-year cycle. I also knew from memory that I had been given a pneumonia vaccine (13 strains covered with that particular year’s vaccine) and both types of meningitis vaccines required. The informative immunologist went on to advise that asplenics have a life-long habit of B-cell waning! I had not heard that piece of information prior to that visit so I paid close attention to the discussion from this specialist. Lymphatic tissue in the body is the birthplace of these “B” cells, B-cell progenitors known as memory B-cells, in addition. Asplenics have a life-long pattern of waning “memory” B-cells in particular (differing from the plain B-cell) . These special cells not only combat invaders in the body’s immune defense system, but they remember the invading organism in an attempt to provide protection against or immunity from the organism, to an extent, in the future. The spleen is the valuable organ within the body that is the largest lymphoid reservoir. I like to think of the spleen as the captain of the ship when it comes to lymphatic tissue due to the spleen’s size when compared to other lymphatic tissue and lymph nodes. B-cells and T-cells are produced in bone marrow stem cells and are part of the body’s defensive cells against foreign antigens (invaders). While both B and T cells are vital in fighting infection, it is the B-cell that is invaluable for its ability to not only aid the T-cells in fighting infection, but the B-cell creates a “memory” cell (memory B-cell) of the immune system, as this specialized cell has the ability to produce antibodies against an invading organism and release the antibodies into the bloodstream or lymphatic tissue present throughout the body. While busying itself with producing antibodies, the B-cell produces memory cells (as well as another component, plasma cells) which aid in recognizing the invading organism in the form of antibodies learned from the prior invasion of the invading organism. This explanation in no way encompasses all specific pathways of lymphoid tissue T and B cells, the information regarding production of these amazing cells and their mechanisms of action in disease fighting is worth taking the time to read each cell’s specific role and genesis, and will serve to demonstrate the ability of the body to heal and protect itself from foreign organisms. An intact immune system is valuable in disease protection but the immune system requires general constitutional assistance. Assistance in the form of adequate rest, balanced diet, health habits with regards to seasonal vaccination(s), good hand washing and avoidance if possible, of people ill with commonplace illnesses such as the common cold, and flu. However people with asplenia have another concern with regard to constitutional assistance, in addition to those mentioned in the previous sentence. The asplenic does not retain all memory B-cells as an individual with an intact spleen would retain. There is a chronic waning within the immune system of asplenics, of memory B-cells. There is still Production of B and T cells by the bone marrow’s stem cells, but a chronic waning of memory B-cells is inevitable in the asplenic person. For this reason the asplenic must remember the 5-year vaccine cycle as mentioned earlier in this essay. The asplenic must keep a record of the last date of immunizations in order to know when the next 5-year cycle will occur. It is amazing how quickly the 5-year cycle seems to return, just my observation. I have noticed in my encounters with physicians providing my care (usually primary care physicians/family practice), that the first question asked of me whenever presenting for care is, “Did you remember your 5-year vaccine cycle?” Yes, the asplenic will be asked about the vaccine cycle typically, because the vaccines are just that important!
One other new verbiage encountered by the asplenic will be the words, “Howell-Jolly bodies.” These bodies are known as inclusion bodies seen on a typical venous blood smear by laboratory personnel. These Howell-Jolly bodies are nothing to fear and nothing, to my knowledge that can be avoided. As the typical 120-day cycle of a red blood cell expires, the intact spleen removes old blood cells as part of the spleen’s role, the liver has this task to some extent as well, but typically the spleen is the organ that will remove old red blood cells from circulation. In the case of anatomic asplenia, there is obviously no spleen to serve in this function. Although the liver joins in the removal process to some extent, a laboratory examiner will notice fragments of the old blood cells that have been targeted for phagocytosis by immune system white blood cells. The Howell-Jolly body inclusions are nuclei of recently-deceased red blood cells still evident on a stained venous blood smear slide in the laboratory. Nothing harmful in any way, just literal remnants of old red blood cells that were not efficiently removed from circulating blood by virtue of the lost spleen in one’s anatomy, remnants still present and noticeable.
The words “helmet cells” may also be noted on a venous blood microscope slide on a laboratory report as another inclusion body. The helmet cell is a snapshot in a sense, of a red blood cell that is becoming the victim of phagocytosis; these may be seen on a slide as blood cells which are flattened on one side as the cell is no longer sporting a rounded shape typical for red blood cells. The cells therefore resemble literal helmets. Again, a product of asplenia and nothing to be feared. The immune system’s white blood cells are actively at work destroying the resemblance of what was once a red blood cell, thus distorting the appearance of the red blood cell in the process of its destruction.
As I became a diabetic sometime later, years after my surgery, I added the concern of checking my A1C readings periodically. As a measure of one’s blood glucose over time, it is always a great idea to have an awareness of the A1C as the diabetic patient will be advised to work to keep one’s A1C under 7, generally, though a patient’s endocrinologist may strive to have the patient’s A1C even lower than 7. In asplenia, it is noted that since there exists older fragments of dying red blood cells, a fructosamine level may be added to lab orders, as fructosamine is akin to checking in on the A1C: The fructosamine laboratory assay is another way to check in on the glucose bound to hemoglobin as in the traditionally known A1C assay. The fructosamine laboratory assay is not as popular as the A1C assay and may be ordered at the same lab draw as the A1C assay. A fructosamine level may be ordered as well as the A1C as typically, such as in my case of asplenia, conditions that affect the red blood cells may dictate the addition of a fructosamine level or assay, and sources I’ve read in the past suggest not only asplenia but other red blood cell -involved conditions such as thalassemia, sickle-cell diseases and any other condition resulting in unusual red blood cell morphology by virtue of the condition itself, not conditions such as traumatic blood loss or dehydration. More chronic conditions are cited, and asplenia fits the bill in this category as well: The “condition” in the case of asplenia is the existence of poorly eliminated, old red blood cells by virtue of the absence of the red blood cell mitigation organ, the absent spleen. Red blood cell fragments which may still harbor some measure of glucose in their destructed state, contribute to the glucose total assay in the case of the fructosamine testing.
My concerns with asplenia as a life-long condition going forward is not the cells over which I have no control, inclusion bodies, but the ongoing awareness I must have of invading organisms that can be problematic, the organisms that are pyogenic, or the root causes of infections. In my 11 years since my splenectomy I have read sources, both old and new, wherein some suggest that asplenics could have available antibiotics at home! Not for me, I believe this idea to be dismissive of one’s ability to seek medical attention at the first sign of suspected infection. Those same sources, both old and new, do however mention that asplenic can become sicker sooner than those with intact spleens: I believe this idea to be more sound than the idea of antibiotics sitting in my nightstand drawer at my convenience, but this belief is only my opinion. I am blessed to have access to urgent care, an asset that can be accessed to assuage my suspicion of a possible infection brewing. These suspicions can also be mitigated through one’s primary care provider if a timely appointment can be obtained when the asplenic notices a change in one’s physical condition. My opinion as a registered nurse is that pre-emptive antibiotics, at the bedside for immediate use (antibiotics on hand), is that one’s medical provider may or may not ascribe to this idea. My primary care provider has never suggested pre-emptive antibiotics available to be taken without medical consultation in the moment, even if the antibiotic is broad-spectrum in its class. The asplenic MUST understand the need for prompt medical attention if an infection is suspected, if one’s body seems “off.” This concept may be explained to the new asplenic prior to their release from the hospital post-surgery.
I will suggest that a new asplenic may have this aforementioned concept of prompt medical assessment in the event of suspected infection, in the discharge instructions provided by the physician upon discharge from the hospital. This idea may be explored by the new asplenic’s primary care physician upon their first visit to the PCP following surgery, though the post-surgical visits will ensue first, upon hospital discharge as is typically the case as an outpatient. The surgeon will require follow up visit(s) post-surgery as per the surgeon’s protocol for the splenectomized patient. This information must also appear in post-op instructions just prior to release from the hospital. If the splenectomy is a planned surgical procedure and not sudden or the case of trauma surgery, the patient should receive information on vaccinations against H. Influenza B, pneumonia, and meningitis (both vaccines for this) prior to surgery. In my case, the hematologist covered the information with me pre-op, however a planned procedure may involve the surgeon’s visit pre-op and not a general practitioner or specialist provider depending on the surgical circumstance.
Infection prevention will be ongoing vigilance for the asplenic person for the duration of the person’s life. One must never discount the 5-year vaccine cycle, the advice of the medical provider whom is thoroughly cognizant of the aplenic’s surgical history, and regular medical check-ups annually. Important as well, is the responsibility of the asplenic person to be aware of one’s own body, the body’s signals that it provides letting one know that something is amiss in one’s general health. It is the asplenic patient whom will appear in the primary care provider or urgent care’s office upon any hint of an infection or just feeling ill. Constitutional maintenance of the body is paramount; one must get adequate rest, stay hydrated and keep as normal a dietary routine as possible in order to give basic support to the wonderful machine that is the human body. In short, simple attention to what is “normal” for one’s body and what seems “abnormal,” is a starting point. Any sort of suspected infection or febrile condition can quickly escalate for the asplenic person as sadly, our body’s ability to defend itself from invading organisms is impaired. Our memory B-cell count lessens over time hence the need for the 5-year vaccine cycle.
It is 11-years on for me, in my journey with asplenia and while not at all perfect, I have managed to abate infections in time to avoid hospitalizations for that ever-present threat of sepsis, while keeping watch over what is normal for my body to feel. I have been very blessed with medical caregivers and of course, on time for my 5-year vaccine cycle. I was a rapt audience the day that I met with an immunologist who emphasized the need for scheduled vaccines due to inevitable waning of memory B-cells (what a wealth of information on that particular day!). It is my responsibility to be aware of what is needed for my body to maintain health in light of asplenia, but so far, living proof that life beyond the removal of a spleen is entirely possible. Note that there exist medical alert bracelets for the “asplenia” conditions and I have also noticed simple, small instructional cards that can be printed indicating the asplenic state- I have one in my wallet in the event of an emergency and I cannot speak for myself. Learning asplenia is a dynamic adventure, but “learning” about this condition is the most valuable resource for the asplenic person to pursue.
References
- Fructosamine
Gounden V., Ngu M., Anastasopoulou C., Jialal, I. [ et al.]
[Updated 2023 Aug 14]. In :StatPearls [Interent]. Treasure Island, (FL):
StatPearls Publishing; 2023 Jan- . Available from https:// www.ncbi.nlm.nih.gov/books/NBK470185/ - Splenectomy Associated Changes in IgM Memory B Cells in an Adult Spleen Registry Cohort
PLOS ONE Open Access Journal Article - PLoS One. 2011; 6(8): e23164. Published online 2011 August 4. Doi: 10.1371/journal.pone.0023164
PMCID: PMC3150402 PMIC: 21829713
Authors: Paul U. Cameron, (superscripts 1,2,3), Penelope Jones, (superscript 2), Malgorzata Gomiak,
(superscript 1), Kate Dunster, (superscript 1), Eldho Paul, (superscript 7), Sharon Lewin, (superscripts 2,4,6), Ian Woolley, (superscripts 2,4,5) and Denis Spelman, (superscripts 1,2) - Jane Deng, Editor
Superscript(s) Reference:
1. Pathology Services, The Alfred Hospital, Melbourne, Victoria, Australia
2. Infectious Diseases Unit, The Alfred Hospital, Melbourne, Victoria, Australia
3. Department of Immunology, Monash University, Melbourne, Victoria, Australia
4. Department of Medicine, Monash University, Melbourne, Victoria, Australia
5. Department of Infectious Diseases, Monash Medical Centre, Clayton, Victoria, Australia
6. Centre for Virology, Burnet Institute, Melbourne, Victoria, Australia
7. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria Australia
University of California Los Angeles, United States of America
Notably:
- Conceived and designed the experiments: (authors) PUC PJ DS IW.
- Performed the experiments: (authors) PUC MG KD.
- Analyzed the data: (authors) PUC MG KD EP PJ.
- Contributed reagents/materials/analysis tools: (authors) PUC EP PJ MG KD IW.
- Wrote the paper: (authors) PUC PJ SL IW DS.