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Antibiotic Therapy Based on Stained Peripheral Blood Smear

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Article
A fatal case of a postsplenectomy sepsis is presented which occurred in a 5-year-old boy 11 month following splenectomy due to trauma and reimplantation of splenic tissue. The patient died 4 h after admission to the hospital. The post mortem revealed an encephalitis and a sepsis although splenic regenerates were found in the omentum pouch. Our report increases the number of cases described to date in the literature to a total of 18. Autologous reimplantation of splenic tissue does not offer complete protection against over-whelming infection.
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Overwhelming infection after splenectomy remains a problem despite the introduction of vaccine and antimicrobial prophylaxis. To evaluate prospectively various procedures proposed for salvage of the spleen, we measured reticuloendothelial function for two to five years in 51 patients who had initially presented with abdominal trauma and suspected splenic rupture. The mean percentage of pocked erythrocytes and the clearance of antibody-coated autologous erythrocytes in 8 patients who had splenic repair and in 6 who had partial splenectomy were the same as in 11 controls with intraabdominal injury that did not involve the spleen. The mean percentage of pocked erythrocytes remained significantly elevated in 19 patients who had undergone total splenectomy without autotransplantation of splenic tissue. One of seven patients who underwent splenic autotransplantation had a normal level of pocked erythrocytes 18 months after surgery, and a second patient had only a slight elevation at 24 months. The mean (+/- SEM) half-time clearance of labeled erythrocytes was significantly longer in the group that had total splenectomy without autotransplantation (421.1 +/- 74.5 hours) than in the autotransplantation group (91.6 +/- 20.0) or in the controls (5.4 +/- 2.0). We conclude that reticuloendothelial function was better preserved after partial splenectomy and splenic repair than after splenic autotransplantation, but that autotransplantation was superior to total splenectomy and appeared to be safe. Splenic autotransplantation deserves further study in patients who have had splenic trauma when other surgical maneuvers to save the spleen are not possible.
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A patient with two prosthetic valves had clinical evidence of infectious endocarditis caused by Clostridium perfringens. The diagnosis was made by routine examination of the peripheral blood smear. To our knowledge, no previous reports have been made of clostridial endocarditis in prosthetic valves with the presence of clostridia in the peripheral blood smear.
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A patient with an incomplete amputation due to a crush injury to his arm developed a myonecrosis with Gram-positive rods noted on muscle and wound aspirates. The patient was treated for a probable Clostridium perfringens infection but culture results proved the organism to be Bacillus cereus. In light of the reported resistance of Bacillus cereus to penicillin, this case serves to emphasize the importance of expanded empiric coverage with high-dose penicillin and an aminoglycoside pending the return of culture and sensitivity results.