In haematological malignancies it is obvious that immune deficiency can occur because of either T- and/or B-cell impairment. Depending upon the clinical situation, travel should be discouraged or appropriate measures should be in place, as mentioned above. Metastatic solid tumour disease will lead to immune suppression, depending on the type and measure of progressive disease. Advice on travel should be in relation to the patient's condition (Karnofski scale). The level of immune deficiency in these patients is often difficult to establish. When travel is considered in such patients, common sense should prevail.
The spleen provides a multitude of important host defence functions. Surgical removal of the spleen, or splenic dysfunction because of disease, results in a heightened predisposition to sepsis caused by pneumococci and other streptococci, H. influenzae, meningococci and a variety of other encapsulated bacteria, such as Capnocytophaga canimorsus. Splenic hypo- or non-function also predisposes to severe infection with intra-erythrocytic parasites such as Plasmodium falciparum, and Babesia microti (after dog bites).
The risk of acquiring these infections in these patients is determined largely by the age at which the splenectomy was performed and the reason for it. If splenectomy is carried out above the age of 5, acquired immunity leads to reduced risk of infectious problems. It is suggested that in post-traumatic splenectomy, splenic cells adhere to the peritoneum and might partially take over splenic function. There is no evidence for this hypothesis. However, the risk of postsplenectomy sepsis after splenectomy for splenic trauma appears to be lower than that found in patients who were splenectomised for other reasons, such as a haematological disorders (malignancy, idiopathic thrombocytopenia, hereditary spherocytosis, etc.). In general, after any splenectomy the risk of developing fulminant sepsis decreases after 2-3 years, but a lifelong increased risk of a serious course of certain infections will exist.
The same problem can be seen in the hypofunctional
A 24-year-old man came for advice before trekking through India and Nepal. He had an IgA deficiency, and had been treated on and off until the age of 18 by a paediatrician with several experimental treatments. He had to be treated regularly for respiratory tract infections and had been plagued by chronic nasal congestion. As a child he had received the usual vaccinations without problems. He received diphtheria-tetanus and polio boosters, typhoid fever vaccine, hepatitis A vaccine, meningococcal A/C vaccine and Haemophilus influenzae vaccine. Instructions were given on the use of standby treatment consisting of co-amoxiclav, spleen, as occurs in sickle cell disease, thalassaemia, certain lymphoid malignancies and irradiated spleens. Before travel, patients without a functioning spleen, or who have undergone splenectomy, need to be protected sufficiently against encapsulated bacteria and malaria. Ideally, before splenectomy, patients should have received pneumococcal vaccination, as the response to pneumococcal vaccine is reduced thereafter. Whether this also applies to other vaccinations is unknown. In pre-travel advice these patients should be given adequate vaccination coverage against pneumococci, menin-gococci A/C, H. influenzae B.
Malaria prophylaxis needs to be optimal, and standby treatment should be available in case of an unexpected breakthrough. Travel to multiresistant malaria fal-ciparum areas without adequate medical facilities should be discouraged. Antimosquito measures are self-evident. In case of fever with or without signs of respiratory tract infection, penicillin treatment (or a macrolide in the case of penicillin allergy) should be started promptly. A thick blood film to exclude malaria should be done without delay at the same time. After bites by dogs or cats immediate prophylactic antibiotic treatment must be initiated, with co-amoxiclav (7 days) or, in case of penicillin allergy, clindamycin (300 mg thrice daily for 7 days).
After treatment she had an uneventful recovery. Because she was eager to continue work in developing countries, all necessary vaccinations and precautions indicated for the splenectomised patient were given. In the following years she was seen twice for a check-up. She had worked in refugee camps in the Middle East and in a public health project in Cameroon, so far without any further problems.
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