Splenectomy. The treatment of choice for human immunodeficiency virus-related immune thrombocytopenia?
T. S. Ravikumar, J. D. Allen, A. Bothe Jr and G. Steele Jr
Department of Surgery, New England Deaconess Hospital, Harvard Medical School, Boston, Mass. 02215.
Immune thrombocytopenia is a well-recognized part of the clinical spectrum
of infection with the human immunodeficiency virus. From November 1985 to
February 1988, 15 patients who were human immunodeficiency virus-positive
underwent splenectomy for refractory immune thrombocytopenia. Eight
patients had thrombocytopenia only, and 7 others were pancytopenic prior to
splenectomy. Three of the 15 patients fulfilled criteria for acquired
immunodeficiency syndrome before splenectomy, and acquired immunodeficiency
syndrome developed in 5 patients during the follow-up period. The median
duration of thrombocytopenia prior to surgical therapy was 6 months. A bone
marrow biopsy specimen showed hypercellularity with increased
megakaryocytes. All patients had a therapeutic response to splenectomy.
Long-term remission from thrombocytopenia/pancytopenia was achieved in 14
of the 15 patients during a follow-up period of 2 to 21 months. Splenectomy
can be accomplished with an acceptable morbidity. Pneumonia developed
postoperatively in 2 patients, but they did not manifest the characteristic
picture of overwhelming postsplenectomy sepsis. They had received
vaccinations against encapsulated organisms preoperatively. We conclude
that splenectomy provides a durable and lasting response for HIV-related
thrombocytopenia. Vaccination for Streptococcus pneumonia and Haemophilus
influenzae should be given prior to splenectomy although its efficacy is
not clear in this group.
