Question of the Week # 306

306) A 32 year old man with history of immune thrombocytopenic purpura is evaluated in your office during a follow up visit. His previous treatments include intravenous immunoglobulin (IVIG) and steroids for his immune thrombocytopenia. He has responded to IVIG in the past however, the response was transient despite steroid maintenance. The patient was maintained on steroids for 2 months initially and achieved a sub-optimal response with peak platelet count reaching 30k/µl. He began very slow steroid taper over the last 4 weeks but his platelets have dropped to 8k/μl again during the taper. Hence, the patient is scheduled for Splenectomy. On examination, he has no bleeding or echymoses. Platelet count today is 10k/μl. Which of the following is the most appropriate step in preparing this patient for surgery?

A) Pneumococcal , Meningococcal and HIB vaccines 1 week prior to surgery

B) Pneumococcal and meningococcal vaccines 2 weeks prior to surgery

C) Pneumococcal, Menigococcal and HIB vaccines 2 weeks prior to surgery

D) Daily oral Penicillin Prophylaxis

E) No vaccines required in adults

10 Responses

  1. E

  2. B) Pneumococcal and meningococcal vaccines 2 weeks prior to surger

  3. b

  4. c

  5. C……..Persons who have had a splenectomy or who have functional asplenia are at increased risk for infection with encapsulated bacteria. Therefore, age-appropriate pneumococcal, meningococcal, and possibly Haemophilus influenzae (Hib) vaccinations should be given 14 days prior to a scheduled splenectomy or after the 14th postoperative day.

    The CDC recommends annual influenza vaccine as well, because secondary bacterial infections can lead to severe disease in this patient population. Boosters are recommended for all bacterial vaccines every five years for asplenic patients.

    MMR contains live viral antigens but is not contraindicated in asplenic patients. Between 2% and 5% of persons do not develop measles immunity after the first dose of the vaccine. The second dose is not a “booster” but another chance to develop immunity. No further administration of MMR is necessary after two doses

    This recomendation is base of Class III evidence: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion.
    • Technology assessment: A technology study which does not lend itself to classification in the above-mentioned format.
    Devices are evaluated in terms of their accuracy, reliability, therapeutic potential, or cost effectiveness.

  6. Do adults need H influenza vaccine???

    • Yes.. one dose

  7. ccc

  8. Answer B)
    The Centers for Disease Control and Prevention (CDC) have developed vaccination recommendations for asplenic patients. For those patients undergoing an elective splenectomy, the CDC recommends vaccination with both the pneumococcal and meningococcal vaccines. These vaccines should be administered at least 2 weeks prior to the scheduled surgery. The pneumococcal vaccine should be readmininstered once after ≥ 5 years have elapsed since the initial vaccination. Although the CDC does not recommend the routine administration of the Haemophilus influenza B vaccine prior to splenectomy, many providers will administer this vaccine as well. An annual influenza vaccine is also recommended for asplenic patients. In the event of an emergent splenectomy, it is recommended to administer the needed vaccinations within 2 weeks following the surgery.

  9. One dose of Hib vaccine should be administered to persons who have functional or anatomic asplenia or sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib vaccination 14 or more days before splenectomy is suggested.
    Recipients of a hematopoietic stem cell transplant should be vaccinated with a 3-dose regimen 6 to 12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses.
    Hib vaccine is not recommended for adults with HIV infection since their risk for Hib infection is low.

    http://www.obgynnews.com/resources/cdc-adult-vaccine-schedule-for-medical-indications.

    13. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used
    1 dose of Hib vaccine should be considered for persons who have sickle cell disease, leukemia, or HIV infection, or who have anatomic or functional asplenia if they have not previously received Hib vaccine.

    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm

    Answer B. I don’t think he needs Hib; risk of infection in adults is low anyway.

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