Fever in the Asplenic Patient

Why we care

  • Fever in a patient with impaired splenic function = early sign of sepsis
  • Infections in this population can develop precipitously with very minimal antecedent symptoms, and can become fulminant and fatal within hours of symptom onset
  • DIC can occur early in the course

Patient population

  • Anatomic Asplenia (post-splenectomy, congenital asplenia)
  • Functional Asplenia (e.g. sickle cell anemia)
  • Hyposplenia (from atrophy, infarction, engorgement, or infiltration of the spleen in chronic dz such as thalassemias, chronic liver disease, HIV/AIDs, immune disorders, or malignancies)
  • If splenic function is in question, you can obtain a peripheral blood smear and check for Howell-Jolly bodies. This is specific but not sensitive. 

Role of the spleen

  • Red pulp: sinusoids filter out larger rigid particles including senescent and/or parasitized red blood cells, as well as unopsonized bacteria. Macrophages here will also eliminate some infected cells or bacteria via phagocytosis, in addition to producing pro-inflammatory cytokines in response to infection 
  • White pulp: houses half of the body’s immunoglobulin-producing B lymphocytes, which are critical for producing antibodies that target polysaccharide antigens on the surface of encapsulated bacteria

Top Infectious Ddx

  • Pneumonia
  • Primary Bacteremia 
  • Meningitis
  • The most common pathogens involved are encapsulated bacteria and blood borne parasites, which the spleen has a large role in clearing


**The single most important thing you can do is obtain blood cultures and administer empiric IV antibiotics without any delay**

  • At minimum, especially if the sides are busy, I would probably bring this patient into cardiac/resus to get IV access and initiate abx and then consider downgrade if appropriate 
  • Aplenic patients are advised by their outpatient docs to take an oral antibiotic that they have on hand and present to the nearest ED immediately 
  • They might have already taken an oral antibiotic but they still need IV antibiotics ASAP
  • Do not delay abx for LP

Antibiotic Choice 

  • Vanc/Ceftriaxone
  • Vanc is mostly to cover beta-lactam resistant S.pneumo
  • Add anaerobic coverage if concerned for a dog/human bite, so swap CTX with Zosyn
  • If recent travel, consider other possible exposures and add the appropriate coverage
  • As always, broaden as needed but Vanc/CTX is at minimum

Other treatment considerations

  • If concerned for meningitis, give dexamethasone
  • Consider giving IVIG


  • CBC, BMP, LFTs 
  • Blood cultures
  • Peripheral blood smear
  • Quant IgG
  • Strep pneumo urine antigen
  • Consider Coags/Fibrinogen/Dimer if concerned for DIC
  • CXR, other imaging as is appropriate
  • Lumbar puncture – but this is often deferred because patient develops DIC

Disposition: Admission for a minimum of 72 hours

May 2024