This patient has moderate splenomegaly with rheumatoid arthritis (lesions) due to Felty's syndrome.

It is a rare complication of rheumatoid arthritis in which there is leukopenia with selective neutropenia and splenomegaly. The bone

marrow is typically hyperplastic. The disease typically manifests late in the course of 'burnt-out' joint disease. The prognosis is poor

because of recurrent Gram-positive infections. The 'large granular lymphocyte syndrome', a pre-malignant disorder of the T

lymphocyte, may mimic Felty's syndrome in rheumatoid arthritis.

Note. Splenectomy does not prevent sepsis and may hasten the onset of malignancy.

It implies removal of erythrocytes, granulocytes or platelets from the circulation by the spleen. Removal of the spleen is indicated

when the underlying disorder cannot be corrected.

Criteria for hypersplenism include the following:

· Enlarged spleen.

· Destruction of one or more cell lines in the spleen.

· Normal bone marrow.

· Hereditary spherocytosis in children.

· Autoimmune thrombocytopenia or haemolytic anaemia not controlled by steroids.

· To ameliorate hypersplenism in Gaucher's disease, thalassaemia, hairy cell leukaemia.

· Symptoms due to massive organomegaly.

The presence of Howell-Jolly bodies (in all), siderocytes and spur cells (in 25% of patients).

Causes of asplenia include:

· Diminished function: sickle cell disease, thalassaemia, coeliac disease, SLE, lymphoma, leukaemia, amyloidosis.

· Surgical removal: hereditary spherocytosis, thalassaemia, lymphoma, idiopathic thrombocytopenia, traumatic rupture.

· Streptococcus pneumoniae, Haemophilus influenzae B, Neisseria meningitidis and malaria parasites pose a significant risk.

· Less common organisms include babesiasis, caused by tick-borne protozoa, and infection with Capnocytophaga canimorus

following a dog bite.