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Splenectomy pre-HIV diagnosis
Nov 18, 2002

I had a splenectomy at age 7 as a result of congenital spherocytosis. After testing positive a little over a year ago my viral load is consistently around 25-30,000 and absolute CD4 has dropped from approx 900 to 550. This doesn't look too bad but my CD4 (originally around 18-19) has been below minimum on my last two tests (11 and 12 respectively). I have been doing some research on surrogate markers for splenectomised HIV patients and it appears that absolute CD4 counts can be deceptively high as a result of this operation. Should I be considering treatment if my CD4 remains below the minimum of 14-15?

Response from Dr. Wohl

Thanks for your thoughtful question. You are correct, not having a working spleen can lead to increases in your absolute CD4 cell count but without a rise in the CD4 percent (the proportion of white blood cells that are CD4 cells). This means that the usual dependence on absolute CD4 cell count in considering when to start HIV therapy goes out the window when the patient has no spleen.

(Data suggest that the CD4 cell count of individuals with HIV who have undergone splenectomy doubles following surgery with little change in CD4 percent.)

In your case, I would use your CD4 percent and viral load to determine when to start HIV treatment. From the data you provide, I'd say you are about at the point where therapy is justified. Please also recall that persons who have no spleen, either because it has been removed or is not functioning, are susceptible to a number of bacterial infections including pneumococcus - a cause of common pneumonia. Pneumovax, a vaccine against this germ, is recommended every 5 years for such persons. I also recommend people without a functioning spleen to contact me or seek medical advice whenever they develop a fever above 38 degrees centigrade. DW



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