It was thought she had a congenital version of asplenia. After getting hemodynamic support and proper antibiotics she recovered from this infection. She got a lumbar puncture which had an elevated white cell count, consistent with bacterial meningitis with a negative gram stain.
The patient in this report suffered from pernicious anemia, hyperthyroidism and whose spleen on autopsy was found to be replaced by fibrous tissue. The first report connecting the presence of a Howell-Jolly body to splenectomy was by Schur in 1908. He described fragmentation of nuclei during expulsion which left behind “pieces” of nuclei, and he additionally noted smaller basophilic granules. During his work, Jolly refined and detailed many of Howell’s descriptions. Justin Marie Jolly was born in 1870 in Melun, now a Paris suburb, obtaining his doctorate in 1898 at the University of Paris. He went on to describe larger granules that would later be described as “Howell’s nuclear particles”. During his work on coagulation, Howell began to observe how granules stained like nuclei. His thesis was on the origin of fibrin in blood coagulation. William Henry Howell was born in Baltimore in 1860 and received a PhD from Johns Hopkins in 1884. What are some other common red blood cells findings to look for in the blood smear? Ischemic disease to spleen or infarction.Sickle cell disease (from auto infarction during sickle cell crises).Surgical removal for trauma and diseases like (hemolytic anemia, idiopathic thrombocytopenia purpura, malignancy).This can be from either having a spleen or it not functioning: What are some causes of impaired splenic function? Additionally, in patients presenting with sepsis from other infections, knowing the spleen is missing can be valuable to making sure you are treating for these organisms until cultures become positive or in case you are unable to confirm the bug. Well, if you already knew she had meningitis you would already be giving the right antibiotics to cover for Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis. However, the diagnosis of bacterial meningitis can often be delayed from variations in presentation. Babesiosis is thought be more common in patients with a non-functioning spleen (3). In addition to Streptococcus pneumoniae, this includes Haemophilus influenzae and Neisseria meningitidis. Of course, the above doesn’t preclude you from empirically covering all organisms until you can confirm a diagnosis. This patient is at risk for any bacteria that are encapsulated. What are the other infections you need to consider with asplenia? Based on the patient’s symptoms/exam and her blood smear, you have a likely diagnosis!
It’s also the most common infection in patients with asplenia (2). The most common pathogen of meningitis is Streptococcus pneumoniae(pneumococcus).
If a patient comes in with sepsis, fever, headache and myalgias, meningitis is very likely. They are usually one of these at most in a red cell, round, dark purple to red in color and often located peripherally on the red blood cell. Howell-Jolly bodies occur where there is no spleen or an non-functioning spleen, referred to as asplenia. They are left over nuclear remnants that are usually removed when blood cells are in the spleen. This is a picture of a red blood cell with a Howell-Jolly body (red arrows).
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