Post-Splenectomy Overwhelming Sepsis Syndrome in a 36-Year-Old Woman 26 Years after Splenectomy

ABSTRACT

INTRODUCTION: Post splenectomy sepsis syndrome usually occurs within the first 3 years of splenectomy however can occur several years later. Given the high mortality and morbidity, early diagnosis and prevention is key in reducing the deleterious clinical outcomes. METHOD(S) We report a 36 year old Caucasian female with a history of ITP treated with splenectomy 26 years prior, allergic to vancomycin and penicillin, who presented with confusion after 2 days of preceding flu like symptoms. On presentation, the patient was in septic shock with purpura fulminans requiring vasopressors. She subsequently developed hypoxic respiratory failure requiring emergent intubation. Initial labs revealed thrombocytopenia & lactic acidosis of 12.9 mmol/L. Daptomycin and clindamycin were started for possible toxic shock syndrome and azithromycin and cefepime for possible pneumonia. The patient was admitted to the MICU where she developed disseminated intravascular coagulation requiring multiple blood transfusions and platelets after blood smear ruled out TTP. Blood cultures grew Streptococcus Pneumoniae and sputum panel revealed coronavirus, adenovirus, haemophilus influenzae and staphylococcus aureus. Patient's course was further complicated by acute kidney injury requiring continuous renal replacement therapy. Within 48 hours of admission, the patient deteriorated further with worsening acidosis, hyperkalemia and lower limb ischemia and subsequently expired despite resuscitative efforts. RESULT(S) Overwhelming post splenectomy infection (OPSI) is most commonly due to strep pneumoniae, neisseria meningitidis and haemophilus influenzae and is characterized by flu-like symptoms succeeded by fulminant sepsis occurring within 24-48 hours. It has a 0.1-0.5% prevalence and a 50%-70% mortality rate. The incidence is highest within the first 3 years of splenectomy, however persons remain at risk throughout their lifetime, with cases reported as late as 65 years. Though no clear diagnostic criteria exists, clinicians must have a high index of suspicion from history of splenectomy and presenting signs & symptoms. CONCLUSION(S) Given the high mortality associated with OPSI even 26 years post splenectomy, OPSI action plan and early symptom recognition are paramount in reducing the risk of clinical decline while seeking medical attention.