Hyposplenism

Prevention and treatment of infection in patients with an absent or hypofunctional spleen: A British Society for Haematology guideline. Published: Apr 2024.

Background Information

Causes of hyposplenism include:

  • Surgical splenectomy
  • Splenic embolisation
  • Functional hyposplenism (medical causes)
    • Sickle cell disease
    • Coeliac disease
    • Haemolytic anaemia (e.g. spherocytosis)

The main complication is the risk of overwhelming infections caused by encapsulated bacteria:
  • Streptococcus pneumoniae (pneumococcus)
  • Neisseria meningitidis (meningococcus)
  • Haemophilus influenzae type b (Hib)

Diagnosis Guidelines

Peripheral blood film findings:
  • Howell-Jolly bodies (nuclear remnants in erythrocytes) on peripheral blood film is indicative of splenic hypofunction
  • Acanthocytes (spur cells)
  • Target cells (codocytes)
  • Spherocytes
  • Heinz bodies
  • Pappenheimer bodies

Blood test findings:
  • Thrombocytosis
  • Leukocytosis

Confirmatory tests:
  • Pitted erythrocyte detection by phase contrast microscopy - gold standard test
  • Nuclear imaging (technetium scintigraphy)

Management Guidelines

  • Patient should carry an alert card (risk of overwhelming infection)
  • Educate about potential risks of overseas travel - esp. malaria and those associated with animal bites

There are 2 main domains of management to prevent overwhelming infection in those with hyposplenism.
 

The following vaccinations are recommended for those with hyposplenism:
 
Vaccination Timing
Influenza Yearly, to provide seasonal protection
COVID-19 2-dose (3 months apart)
Pneumococcal One-off (irrespective of piror vaccination), then 5-yearly booster
Meningococcal ACWY One-off (irrespective of prior vaccination)
Haemophilus influenzae To be given as part of routine childhood immunisation

Routine re-vaccination is NOT recommended

Vaccines should ideally be administered 2 weeks before or 2 weeks after splenectomy

 

If one learns the at risk encapsulated bacteria listed above (pneumococcus, meningococcus, Hib) + influenza and COVID-19, that's essentially what vaccination should be given to those with hyposplenism.

3 main scenarios: 
 
Duration Indications
1-3 years post-splenectomy ALL patients
Until 5 y/o (with at least 2 complete years of prophylaxis) ALL children
Lifelong Continued high risk of pneumococcal infection:
  • <5 y/o and >65 y/o
  • History of invasive pneumococcal disease
  • Ongoing immunosuppression
  • Splenectomy for haematological malignancy
 

Aim to prevent pneumococcal infection:
  • 1st line: phenoxymethylpenicillin (penicillin V)
  • 2nd line: erythromycin
Author: Adams Lau
Reviewer:
Last edited: 28/08/25