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Late Effects of the Immune System

    Spleen

    Surgical or functional splenectomy increases risk of life-threatening invasive bacterial infection.[1] Although staging laparotomy is no longer standard practice for pediatric Hodgkin lymphoma, patients from earlier time periods have ongoing risks.[2,3] In addition, children may be rendered asplenic by radiation therapy to the spleen in doses greater than 30 Gy.[4,5] Low-dose involved-field radiation (21 Gy) combined with multiagent chemotherapy did not appear to adversely affect splenic function as measured by pitted red blood cell assays.[5] No other studies of immune status after radiation therapy are available. Functional asplenia (with Howell Jolly bodies, reduced splenic size and blood flow) after bone marrow transplantation has been attributed to graft-versus-host disease (GVHD).

    A pneumococcal vaccine booster is recommended for patients aged 10 years and older and more than 5 years after previous dose.[6] Asplenic patients should also be immunized against Neisseria meningitidis and Haemophilus influenzae type B and should receive antibiotic prophylaxis for dental work.

    Prophylactic antibiotics (penicillin or similar broad-spectrum agent) have been recommended for at least 2 to 3 years after splenectomy and until at least 5 years of age for young children.[7] Randomized studies that address the benefit of daily prophylactic antibiotics have not been conducted in a pediatric oncology population; thus, these recommendations are based on extrapolated study data derived from other populations with asplenia.[8,9,10,11] The benefit of prolonged antibiotic prophylaxis is also unknown. Many patients, over time, discontinue use of penicillin; consideration should be given to ensuring availability of appropriate antibiotics for use at the first onset of febrile illness in patients who are not on daily prophylaxis. Medical care should be sought promptly for fevers higher than 38.5°C.

    Table 12. Spleen Late Effects

    Predisposing TherapyImmunologic EffectsHealth Screening/Interventions
    GVHD = graft-versus-host disease; HSCT = hematopoietic stem cell transplantation; IgA = immunoglobulin A; T = temperature.
    Radiation impacting spleen; splenectomy; HSCT with currently active GVHDAsplenia/hyposplenia; overwhelming post-splenectomy sepsisBlood cultures during febrile episodes (T >38.5°C); empiric antibiotics
    HSCT with any history of chronic GVHDImmunologic complications (secretory IgA deficiency, hypogammaglobulinemia, decreased B cells, T cell dysfunction, chronic infections [e.g., conjunctivitis, sinusitis, and bronchitis associated with chronic GVHD])History: chronic conjunctivitis, chronic sinusitis, chronic bronchitis, recurrent or unusual infections, sepsis
    Exam: attention to eyes, nose/sinuses, and lungs
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