Immunologic consequences of neonatal splenectomy

Immunologic Consequences of Neonatal Splenectomy By J. Merikanto, O. Ruuskanen, J. Eskola, P. Ruutu, and I. Louhimo Turku a n d Helsinki, Finland 9 The hazard of overwhelming postsplenectomy infection has been suggested to be greatest in children operated upon before 1 yr of age. In this work immune functions of 3 children, splenectomized within 2 days after birth were studied. The opsonic activity of the sera of all patients towards pneumococcus was decreased. The other immunologic findings were normal. These observations support the concept that all splenectomized patients should receive pneumococcal polysaccharide vaccine and in case of any infection adequate antibiotic therapy must be started very soon after the first symptoms. INDEX WORDS: infection.

Splenectomy;

postsplenectomy

were negative. The child is now well 12 mo after the operation. No antibiotic prophylaxis has been used.

Patient 2 This is the 6th child of a 40-yr-old Rh-negative mother. During pregnancy anti-D titer was elevated and the labor was induced 6 wk before estimated time of delivery. The female infant was normally born, weighed 2430 g with Apgar score of 9. Four blood exchanges were performed because of fetal erythroblastosis. At 1 day of age an intraabdominal hemorrhage was evident, laparotomy was immediately performed and a lacerated spleen removed. This child has developed normally and there have been no severe infections. No antibiotic prophylaxis has been used.

Patient 3

INCE the report of King and Shumacker in 19521 considerable interest has been focused on the risk of overwhelming infections after splenectomy in childhoodY Fatal postsplenectomy infections seem to predominate in patients with serious underlying systemic disorders. The incidence of sepsis is relatively low following removal of a traumatized spleen, but the fatality rate is exceedingly high in these cases, too. 2'3 Rupture of the spleen is rare in the newborn; only 24 successfully treated cases have been reported in the literature. 4 No immunologic studies have been reported in these children, although the susceptibility to overwhelming postsplenectomy infection has been suggested to be greatest in children operated upon before 1 yr of age. 5

S

CASE REPORTS

Patient 1 This is the first child of 25-yr-old mother. The pregnancy was normal and the fullterm female infant weighed 2900 g with Apgar score of 9. On the following day a diaphragmatic hernia on the left side became obvious both clinically and radiologically. Laparotomy was performed and the diaphragmatic defect was closed. The spleen had been lacerated in the herniation and it was removed. On the second postoperative day septicemia was suspected and the child was treated with cephalothin. Blood cultures were however negative. At subsequent examinations up to 4 yr of age the child had grown normally and there were no major infections. At the age of 4 yr a subphrenic abscess appeared on the left side. Staphylococcus aureus was isolated and the abscess was successfully treated with canalization and cloxacillin. All blood cultures

Journal of Pediatric Surgery, Vol. 15, No. 5 (October), 1980

This is the second child of 21-yr-old Rh-negative mother, whose anti-D titer was elevated during pregnancy. Labor was induced 2 wk before the estimated time and the male infant weighed 2970 g with Apgar score of 9. at birth a very serious fetal erythroblastosis was obvious and blood exchanges were performed three times. At 1 day of age symptoms of an intraabdominal hemorrhage suddenly appeared, laparotomy was done and a ruptured spleen removed. The child has grown normally, no susceptibility to infections has been noticed, No antibiotic prophylaxis has been used. MATERIALS AND M E T H O D S Standard methods were used for the measurement of leukocyte differential and platelet counts. The concentrations of IgG, IgM, and IgA and complement C3 and C4 were measured by" single radial immunodiffusion (Behringwerke, Marburg, West Germany). The number of cells forming rosettes with sheep erythrocytes (E-rosettes) and cells forming rosettes with sheep erythrocytes coated with immunoglobulin and complement (EAC-rosettes) were determined by the techniques recommended by WHO. 6 The responses of peripheral blood lymphocytes to phytohemagglutinin (PHA), concanavalin A (Con A), and purified protein derivative of tuberculin (PPD) in vitro were assessed by our routine micromethod using whole blood, r The antibodies for viral and bacterial antigens and isoagglutinins for blood

From the Division of Pediatric Surgery and Departments of Pediatrics and Medical Microbiology, University of Turku and Departments of Serology and Immunology, and Pediatrics, University of Helsinki, Finland. Address for reprint requests to Dr. J. Merikanto, Department of Pediatrics, University of Oulu, SF-90100 Oulu 10, Finland. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1505-0011501.00/0

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MERIKANTO ET AL.

group antigens were determined by standard methods. All children had received the usual pertussis, diphtheria, tetanus, and polio vaccination schedule. The effect of booster vaccination was studied 2 wk after the vaccination. The opsonic activity towards pncumococcus was assessed by the modification of the method described by Ruutu. 8 In brief, pneumococcus, killed with formalin and washed with saline, was added to a cell suspension containing 5 x 106 neutrophils per ml and 80% control or patient serum, in a ratio of one bacterium to one neutrophil. The tubes were incubated at 37~ and mixed occasionally for 8 min. Thereafter, smears for microscopy were made and stained with Wright's stain. Phagocytic index, the average number of bacteria phagocytized by one neutrophil, was determined from 200 cells. Student's t-test was used to estimate the significance,

RESULTS AND DISCUSSION

The results indicate a deficiency of the opsonic activity in the sera of the neonatally splenectomized children (p < 0.01 when compared to the age-matched controls) towards

pneumococcus (Table 1), the bacterium which is the principal causative organism in postsplenectomy sepsisY Our findings are consistent with the previous observations showing diminished or absent opsonins to E. coli in 16 of 22 patients 1-20 yr after splenectomy for traumatic rupture of the spleen in later childhood. 9 Furthermore, Biggar et al. have shown in rats, that splenectomy induces a serum defect in pneumococcal phagocytosis. ~~ Winkelstein and Lambert, however, have found normal pneumococcal opsonizing activity of the serum in 23 children splenectomized for several reasons at older ages. 11 They concluded that other abnormalities after splenectomy could contribute to the increased susceptibility to fulminant bacterial sepsis. The discrepancy between the results by others and us and those by Winkelstein and Lambert may be due to the difference of the age when the splen-

Table 1. Immunologic Data of the Three Neonatally Splenectomized Children

Age, yr Leukocytes/mm z Lymphocytes (%) Thrombocytes/mm 3 E-rosettes (%) EAC-rosettes (%) PHA-response, cpm (stimulation index) Con A-response, cpm (stimulation index) PPD-response, cpm (stimulation index) IgG g/I IgM g/I IgA g/I C3 g/I C4 g/I Peripheral blood smear Diphtheria, lu/ml After booster vaccination Tetanus, lu/ml After booster vaccination Polio, inactivated vaccine, (types 1, 2 and 3) After booster baccination Measles Meningococcus A, p,g/ml After vaccination Isoagglutinis for blood group antigens Opsonic serum activity towards pneumococcus Age-matched control

Patient 1

Patient 2

Patient 3

4 15,200 50 470,000 64 44

7 15,300 46 500,000 63 31

11 5,000 55 300,000 60 38

30,848 582)

20,979 (223)

35,316 (425)

33,760 (637)

30,832 (328)

30,002 (361)

384 (3) 10.0 0.6 0.7 1.1 0.24 Normal No Howell-Jolly bodies 0.1 5.0 1.0 >10.0

313 (7) 10.1 0.7 1.0 1.2 0.30 Normal No Howell-Jolly bodies 0.1 N.D. 1.0 N.D.

2,196 (13) 16.9 1.0 1.5 1.1 0.10 Normal No Howell-Jolly bodies 1.0 5.0 1.0 >10.0

16 16 32 512 128 128 1:64 (Vaccinated) 0.44 8.83

>256

>256 >256 N.D. N.D. 2.77 (Vaccinated)

Anti-B 1:8

Anti-A 1:64 Anti-B 1:32

32 128 64 >512 >512 >512 1:32 (After disease) 2.34 (Vaccinated) Anti-A 1:32 Anti-B 1:8

0.28 0.46

0.20 0.43

0.23 0.58

NEONATAL SPLENECTOMY

653

e c t o m y has been p e r f o r m e d and also to the differences in the opsonic assay. W i n k e l s t e i n and L a m b e r t even propose t h a t the m e t h o d they e m p l o y e d m a y have l a c k e d sufficient sensitivity to identify m i n o r defects in serum opsonizing activity in their patients. 1~ In this study the only pathologic finding was the a b n o r m a l s e r u m opsonic activity, a l t h o u g h the children were splenectomized i m m e d i a t e l y a f t e r birth. T h e o t h e r n o r m a l i m m u n e functions ( T a b l e 1) m a y be due to splenosis, w h i c h has been suggested to occur frequently after laceration of the spleenJ 2 O u r observations a g r e e with a previous study in which no a b n o r m a l i t i e s were f o u n d in l y m p h o c y t e s u b p o p u l a t i o n s a n d responses to mitogens before and after elective splenectomyJ 3 T h e observations support the concept presented r e c e n t l y t h a t all splenectomized patients should receive p n e u m o c o c c a l p o l y s a c c h a r i d e v a c c i n e J 4 In this work good response was observed to n u m e r o u s vaccines. W i t h polyvalent p n e u m o c o c c a l vaccine it i s possible to achieve a protective effect a g a i n s t Diplococcus pneumoniae and this effect lasts for at least 2 y r J 5 T h e subcutaneous route of the vaccination seems to c i r c u m v e n t the need for the splenic i m m u n e response. It m u s t be e m p h a s i z e d t h a t polyvalent p n e u m o c o c c a l vaccine gives protection only a g a i n s t 14 serotypes, which, however, cover at least 80% of the serotypes causing clinical infec-

tions. 16 F u r t h e r m o r e , children less t h a n 2 yr old respond poorly to p n e u m o c o c c a l vaccine and for these children vaccination is not r e c o m m e n d e d . It is also noteworthy t h a t some of the infections in patients splenectomized after t r a u m a are caused by other b a c t e r i a t h a n pneumococci. T h e s e infections can not usually be prevented by vaccinations; instead, in case of an infection, t h e y d e m a n d a r a p i d bacteriologic diagnosis and i m m e d i a t e a n t i b i o t i c therapy. A n o t h e r i m p o r t a n t aspect is t h a t nonoperative m a n a g e m e n t of splenic t r a u m a is r e c o m m e n d e d in selected children whose clinical condition is stable or can be m a i n t a i n e d s t a b l e J 7 The risk o f this form of t h e r a p y lies in missing an associated serious injury. Therefore, surgical r e p a i r of the splenic injury seems to combine the a d v a n t a g e s of splenic preservation with the a d v a n t a g e of l a p a r o t o m y to rule out associated injuriesJ 8 Nevertheless, the crucial point in the prevention of the fatal p o s t s p l e n e c t o m y sepsis is to inform the p a r e n t s of the risk a n d to t r e a t the child i m m e d i a t e l y with an efficient antibiotic according to c a u s a t i v e o r g a n i s m each time the s p l e n e c t o m i z e d child gets an a c u t e febrile illness) 9 ACKNOWLEDGMENT

The authors wish to thank Drs. Tapani Kuronen, and Kaisa Lapinleimu for the measurement of the specific antibodies for viral and bacterial antigens.

REFERENCES

1. King H, Shumacker HB: Splenic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg 136:239-242, 1952 2. Singer DB: Postsplenectomy sepsis. Perspect Pediatr Pathol 1:285-311, 1973 3. Gopal V, Bisno AL: Fulminant pneumococcal infections in 'normal' asplenic hosts. Arch Intern Med 137:15261530, 1977 4. Matsuyama S, Suzuki N, Nagamachi Y: Rupture of the spleen in the newborn: Treatment without splenectomy. J Pediatr Surg 11:115-116, 1976 5. Claret I, Morales L, Montaner A: Immunological studies in the postsplenectomy syndrome. J Pediatr Surg 10:5964, 1975 6. WHO/IARC report: Identification, enumeration, and isolation of B and T lymphocytes from human blood Scand J Immunol 3:521-532, 1974 7. Eskola J, Soppi E, Viljanen M, et al: A new micromethod for lymphocyte stimulation using whole blood. Immunol Commun 4:297-307, 1975 8. Ruutu T: Effect of phenothiazines and related

compounds on phagocytosis and bacterial killing by human neutrophilic leukocytes. Ann Med Exp Biol Fenn 50:2436,1972 9. Passl R, Eibl M, Egkher E, et al: Splenektomie im Kindesalter aus traumatischer Ursache und ihre Folgen. Wien Klin Wochenschr 88:585-588, 1976 10. Biggar WD, Bogart D, Holmes B, et al: Impaired phagocytosis of Pneumococcus type 3 in splenectomized rats. Proc Soc Exp Biol Med 139:903-908, 1972 11. Winkelstein JA, Lambert GH: Pneumococcal serum opsonizing activity in splenectomized children. J Pediatr 87:430-433, 1975 12. Pearson HA, Johnston D, Smith KA, et al: The born-again spleen. Return of splenic function after splenectomy for trauma. N Engl J Med 298:1389-1392, 1978 13. Andersen V, Cohn J, S~rensen SF: Immunological studies in children before and after splenectomy. Acta Paediatr Stand 65:409 415, 1976 14. Sullivan JL, Ochs HD, Schiffman G, et al: Immune response after splenectomy. Lancet 1:178-181, 1978 15. Ammann AJ, Addiego J, Wara DW, et al: Polyvalent

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pneumococcal-polysaccharide immunization of patients with sickle-cell anemia and patients with splenectomy. N Engl J Med 297:897-900, 1977 16. Mufson MA, Kruss DM, Wasil RE, et al: Capsular types and outcome of bacteremic pneumococcal disease in the antibiotic era. Arch Intern Med 134:505-510, 1974 17. Howman-Giles R, Gilday DL, Venugopal S, et al:

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Splenic trauma-nonoperative management and long-term follow-up by scintiscan. J Pediatr Surg 13:121-126, 1978 18. Burrington JD; Surgical repair of a ruptured spleen in children. Arch Surg 112:417-419, 1977 19. Gellis SS: Immunologic studies in the postsplenectomy syndrome, in Gellis SS (ed): Year Book of Pediatrics. Chicago, Year Book Medical Publishers, 1976, pp 108-110