A 23-year-old man is brought to the emergency department after a motor vehicle collision. He is in distress and has severe abdominal pain and distension. The patient undergoes urgent laparotomy, which reveals a splenic laceration with significant bleeding. Splenectomy is performed, and the patient does well postoperatively. He has no significant medical history. The patient drinks alcohol occasionally but does not use tobacco or illicit drugs. He received all childhood vaccinations but has not had any vaccines in the past 10 years. Which of the following vaccinations is recommended for this patient?

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Explanation: 11ec25c8_d923_7825_bc81_9d1f02122e9a_MD0003_00 The spleen plays an important role in immune surveillance. Splenic dendritic cells identify antigens in the blood and present them to helper T-lymphocytes, which then stimulate B-lymphocytes to differentiate into antibody-secreting plasma cells. The antibodies that stimulated plasma cells generate are required for efficient, phagocyte-mediated destruction of encapsulated pathogens (eg, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae). Without the spleen, patients have an insufficient antibody response to these organisms and are at tremendous risk for rapid-onset fulminant infection, particularly with S pneumoniae. Therefore, patients age >19 who require splenectomy should receive the following vaccinations to ensure adequate immunity against the most common encapsulated pathogens: Pneumococcus: The 13-valent pneumococcal conjugate vaccine (PCV13) should be given first, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) >8 weeks later. Patients need revaccination with PPSV23 5 years later and again at age 65. H influenzae type B (Hib): Patients are generally given a single dose of Hib regardless of previous vaccination status because antibody titers tend to decrease over time. Revaccination (booster) is not required. Meningococcus: Patients undergo vaccination with both the meningococcal quadrivalent vaccine and the vaccine targeted toward meningococcus group B. Meningococcal quadrivalent vaccination should be repeated every 5 years. The tetanus-diphtheria-acellular pertussis (Tdap) and hepatitis vaccines (both hepatitis A and B) should be given according to standard guidelines for nonsplenectomized patients. Herpes zoster vaccination is not required for young adults who undergo splenectomy; reactivation with this organism is not increased because the immune response against viral pathogens is primarily cytotoxic T-cell (not antibody) mediated. All patients should receive vaccines either ≥14 days before scheduled splenectomy or ≥14 days after splenectomy. Although antibody titers are comparable if vaccines are given within 14 days of splenectomy, the functional activity of the antibodies is lower in these patients than in those receiving the vaccines 14 days later. Educational objective: Following splenectomy, patients are at increased risk for sepsis due to encapsulated organisms, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Vaccinations against each of these organisms should be administered either ≥14 days before scheduled splenectomy or ≥14 days after splenectomy. References: Recommended vaccinations for asplenic and hyposplenic adult patients. (http://www.ncbi.nlm.nih.gov/pubmed/27929751)

A 23-Year-Old Man Is Brought to the Emergency Department After