www.medscape.com Overwhelming Post-splenectomy Infection (OPSI)A Case Report and Review of the LiteratureTrent L. Morgan, MD, CPT, MC, USAF, Eric B. Tomich, DO, CPT, MC, USAJ Emerg Med. 2012;43(4):758-763. Abstract and IntroductionAbstractBackground Overwhelming post-splenectomy infection (OPSI) is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short time period. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment, and therefore, it is important for Emergency Physicians to be familiar with it. Patients who are asplenic or hyposplenic are at an increased risk for infection and death from encapsulated organisms and other dangerous pathogens.Objectives There is an abundance of literature discussing OPSI from the perspective of hematologists and infectious disease specialists, but an Emergency Medicine perspective is necessary to truly understand the acute nature of the disease. The objective of this article is to present a careful examination of the literature with a focus on early diagnosis and management to provide Emergency Physicians with the ability to positively affect outcomes of this deadly disease.Case Report We present the case of a well-appearing 5-month-old girl with congenital asplenia who presented to the Emergency Department with fever, and rapidly progressed to septic shock as a result of OPSI. Aggressive resuscitation was initiated, including empiric antibiotics, and after a prolonged hospital course in the pediatric intensive care unit, the child recovered.Conclusion Rapid identification of patients at risk for OPSI, followed by administration of intravenous antibiotics, usually vancomycin and ceftriaxone, combined with early goal-directed therapy, are the keys to successful treatment. If initiated early in the patient's course, the 70% mortality rate can be reduced to the 1040% range.IntroductionOverwhelming post-splenectomy infection (OPSI) is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short time period. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment, and therefore it is important for Emergency Physicians to be familiar with it. Patients who are asplenic or hyposplenic are at an increased risk for infection and death from encapsulated organisms and other dangerous pathogens. The objectives of this article are to review the literature discussing OPSI from the perspective of the Emergency Physician and to understand the acute nature of the disease. Careful examination of the literature with a focus on early diagnosis and management provides Emergency Physicians with the ability to positively affect outcomes of this deadly disease.Case ReportA 5-month-old girl was brought to the Emergency Department (ED) by her mother with a chief complaint of fever (38.1C oral), fussiness, and cough for several hours. The patient had a history of duodenal atresia, midgut malrotation, congenital asplenia, and an undiagnosed liver disorder. She was born at 36 weeks gestation and spent some time in the neonatal intensive care unit. She was hospitalized 1 month before presentation for a fever of unknown origin that was treated with empiric intravenous (i.v.) antibiotics, from which she recovered without incident. Her immunizations were up to date. The patient's mother denied sick contacts, diarrhea, bloody stools, difficulty breathing, rhinorrhea, or lethargy. The patient was taking oral feeds with adequate urine output and had a single episode of vomiting. She was given a dose of acetaminophen before arrival. On examination, the patient was afebrile (37.6C [99.8F] rectal), non-toxic, smiling, and interactive. She was diffusely jaundiced and had scleral icterus that had been present for weeks. The remainder of her physical examination was unremarkable. Laboratory tests were significant for a white blood cell count (WBC) of 36,000 cells/mm 3 with 23% bands, and venous hemoglobin of 6 gm/dL. Liver function studies were grossly abnormal, with coagulation times mildly prolonged. Venous lactate was 2.1. Urinalysis and serum chemistry were unremarkable. Two sets of blood cultures were also obtained. A chest radiograph was normal. After discussion with a pediatric infectious disease specialist, ceftriaxone 50mg/kg i.v. was ordered. The patient was admitted to the pediatric service, where several hours later she developed respiratory depression, lethargy, and signs of septicemia and disseminated intravascular coagulopathy (DIC). She was intubated and central venous access was obtained. Ceftriaxone dose was increased to 100mg/kg and vancomycin was added. Crystalloid and blood product resuscitation was initiated along with vasopressor agents. A lumbar puncture was unremarkable. In60mL/min (approximates 1g i.v. q 12h for 70kg adult)PLUSCeftriaxone 2g i.v. daily (children=50mg/kg i.v. q 12h)ORCefotaxime 2g i.v. q 8h (children=2550mg/kg i.v. q 6h)Regimen if anaphylaxis to -lactam Vancomycin 1015mg/kg i.v. q 12h if CrCl>60mL/min (approximates 1g i.v. q 12h for 70kg adult)PLUSLevofloxacin 750mg i.v. q 24hAdd if concern for Capnocytophaga canimorsus Clindamycin 300600mg i.v. q 6h (children>1 month old=2540mg/kg/day i.v./i.m. divided q 68h with max 4.8g/day)ORImipinem/cilastatin 500 mg1g i.v. q 6h (children=60100mg/kg/day i.v. div q 6h with max 24g/day)ORPiperacillin/tazobactam 3.3754.5g i.v. q 6h if CrCl>40mL/min (children=300mg/kg/day i.v. div q 8h)OPSI=overwhelming post-splenectomy infection; i.v.=intravenous; i.m.=intramuscular; q=every; CrCl=creatinine clearance.ConclusionOPSI is an extremely serious infection that often quickly progresses to fulminant sepsis, resulting in high mortality rates. Emergency Physicians are well trained to diagnose and treat sepsis, but not specifically in asplenic patients. This subclass of patients progress from healthy to clinically septic so quickly that it is imperative that Emergency Physicians not only recognize OPSI, but effectively treat it early. Current literature suggests a combination of i.v. vancomycin and ceftriaxone in combination with early goal-directed therapy. The use of IVIG is unproven, and may not be immediately available in the ED. If used, it likely will be given as an inpatient treatment with consultation from infectious disease specialists. Implementation of these strategies may reduce mortality from 70% to around 1040%. [2]References Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis Clin North Am 1996;10:693707. Brigden ML. Overwhelming postsplenectomy infection still a problem. West J Med 1992;157:4403. Sawmiller CJ, Dudrick SJ, Hamzi M. Postsplenectomy Capnocytophaga canimorsus sepsis presenting as an acute abdomen. Arch Surg 1998;133:13625. Rivella S. Ineffective erythropoiesis and thalassemias. Curr Opin Hematol 2009;16:18794. Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg 1991;78:10318. Rosner F, Zarrabi MH, Benach JL, et al. Babesiosis in splenectomized adults. Review of 22 reported cases. Am J Med 1984;76: 696701. Krause PJ, Gewurz BE, Hill D, et al. Persistent and relapsing babesiosis in immunocompromised patients. Clin Infect Dis 2008;46: 3706. Waghorn DJ. Overwhelming infection in asplenic patients: current best practice preventive measures are not being followed. J Clin Pathol 2001;54:2148. Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect 2001;7:65760. Di Cataldo A, Puleo S, Li Destri G, et al. Splenic trauma and overwhelming postsplenectomy infection. Br J Surg 1987;74:3435. GopalV, Bisno AL. Fulminant pneumococcal infections in 'normal' asplenic hosts. Arch Intern Med 1977;137:152630. Thomsen RW, Schoonen WM, Farkas DK, et al. Risk for hospital contact with infection in patients with splenectomy: a populationbased cohort study. Ann Intern Med 2009;151:54655. Lawrence T, Puel A, Reichenbach J, et al. Autosomal-dominant primary immunodeficiencies. Curr Opin Hematol 2005;12:2230. Okabayashi T, Hanazaki K. Overwhelming postsplenectomy infection syndrome in adultsa clinically preventable disease. World J Gastroenterol 2008;14:1769. Konradsen HB, Pedersen FK, Henrichsen J. Pneumococcal revaccination of splenectomized children. Pediatr Infect Dis J 1990;9: 25863. Stryker RM, Orton DW. Overwhelming postsplenectomy infection. Ann Emerg Med 1988;17:1614. El-Alfy MS, El-Sayed MH. Overwhelming postsplenectomy infection: is quality of patient knowledge enough for prevention? Hematol J 2004;5:7780. J Emerg Med. 2012;43(4):758-763. 2012 Elsevier Science, Inc.