Letter to editor: Re: “Prevalence of HIV, hepatitis B and hepatitis C infections among patients with thalassemia attending a tertiary care (rural) hospital”

Dear Editor,

‘Prevalence of HIV, hepatitis B and hepatitis C infections among patients with thalassemia attending a tertiary care (rural) hospital’, by Mandal et al.[1] published in your esteemed journal, was an interesting read. Unrestricted destruction of abnormal erythrocytes due to ineffective erythropoiesis resulting in extra-medullary hematopoiesis in β-thalassemia major contributes to splenomegaly, hypersplenism and increased requirement of blood transfusion. The outcome often necessitates splenectomy in patients.[2] However, it is significantly associated with long-term complications, like pulmonary hypertension, thrombosis and sepsis.[3,4] Overwhelming post-splenectomy infection (OPSI) is a common outcome in patients which may contribute to a high-mortality rate.[4,5]

Paul et al.[2] reported recurrent infections in 12.5% of patients at follow-up and peri-operative sepsis in 3.8% of patients, in a study involving 26 splenectomized thalassemic patients aged between 5 and 18 years. A three-year study on 1,380 registered Eβ-thalassemia patients by Mandal et al.[6] reported 72 splenectomized cases. Infections mainly by gram-negative bacteria like Escherichia coli, Klebsiella pneumoniae, Pseudomonas spp. and Streptococcus pneumoniae with severe outcomes were reported in 6.96% of splenectomized patients. Two patients suffered from Plasmodium infection. A significantly high-mortality rate associated with peri-transplant infections (24% vs. 5.3%; P = 0.0001) in post-splenectomized (n = 29) versus non-splenectomized (n = 76) β-thalassemia major patients was reported for an allogenic stem cell transplant by Mathews et al.[7] Another study by Patole et al.[8] reported two out of 20 thalassemia patients with impaired immune function post-splenectomy, with one infection of oral candidiasis. A study was conducted by Bhattacharjee et al.[3] between July 2013 and March 2024 on 103 adult splenectomized transfusion-dependent thalassemia patients (≥18 years). OPSI was reported in 3.9% of patients, while majority of the patients developed OPSI within two years of splenectomy.

Although splenectomy has a vital role as a treatment procedure for patient with thalassemia major,[9] given the importance of spleen in immunological functions, a splenectomized patient is at a higher risk of infection post-amputation. This necessitates an extensive and succinct knowledge of splenectomy-associated complications in India, contributing to approximately 25% of the global β-thalassemia burden and majority of the patients being from lower income group.[10] These patients have inadequate health facilities and depend on government-aided health institutes for treatment. In spite of improved treatment modalities, splenectomy-associated infection still remains a major concern in our country. The study by Mandal et al.[1] focuses on the proportion of four viral transfusion-transmitted infections (TTIs) in thalassemia patients attending the only available government-run rural tertiary care centre in a region of Sunderban (West Bengal). A subset of 2.63% of the patients were reported to be splenectomized, but contribution of splenectomy to infections upon comparison with non-splenectomy cases has not been delved into. Hence, such studies from India will be more insightful if an extensive elucidation of the impact of splenectomy and propensity for different infections including but not limited to viral infections is reported, besides TTIs.

Author Contributions

BC and SS have drafted the editorial. RD has edited and primarily proof read the write-up. All three authors have reviewed and approved the write-up for submission.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.