Fulminant post-splenectomy sepsis (OPSI)

Specialty: Hematology.

• Overwhelming post-splenectomy infection syndrome
• OPSI
• hyperacute asplenic sepsis

Why it occurs

• Previous surgical splenectomy for massive splenic trauma or hematological indication (such as in refractory hereditary spherocytosis, resistant immune thrombocytopenic purpura or lymphoproliferative syndromes; the loss of the spleen eliminates the main macrophage filter of the body capable of purifying non-opsonized capsulated bacteria, as well as the production of IgM antibodies and properdin)
• Functional asplenia secondary to sickle cell anemia (autosplenectomy for repeated splenic microinfarcts in childhood)
• Congenital splenic agenesis
• Massive destructive splenic amyloidosis
• Splenic atrophy associated with severe untreated celiac disease.

Initial workup

Serial peripheral blood cultures (minimum two samples from different anatomical sites for aerobes and anaerobes) that must be obtained immediately and without delaying under any circumstances the start of broad-spectrum empirical antibiotic therapy; complete blood count with urgent peripheral blood smear (the observation of Howell-Jolly bodies inside the erythrocytes objectively confirms the patient's state of functional or anatomical asplenia); arterial blood gas with determination of serum lactate (indicator of systemic tissue hypoperfusion); emergency coagulation profile to rule out DIC (prolonged PT, sharply falling plateletopenia, consumed fibrinogen, increased D-Dimer); serum procalcitonin.

Standard management

• Ceftriaxone or Cefotaxime — third generation cephalosporins for immediate intravenous administration at maximum meningeal penetration doses; first choice drugs due to their excellent bactericidal spectrum against Streptococcus pneumoniae and other common capsule pathogens
• Vancomycin — associated intravenously if there is local suspicion of pneumococcus strains with intermediate or high resistance to penicillins
• Mandatory prophylactic vaccines — should be administered on a scheduled basis at least 14 days before a scheduled splenectomy, or 14 days after the emergency procedure; includes pneumococcal conjugate vaccine, meningococcal conjugate and infectious vaccine for serogroups A, C, W, Y and B, and vaccine against Haemophilus influenzae type b
• Penicillin V for daily oral prophylactic use (especially indicated in asplenic pediatric patients during the first years post-splenectomy or in adults with added severe immunodeficiency).