Case Presentation: A 64-year-old male with a history of idiopathic portal vein hypertension requiring splenectomy at age four, COPD, and treated lung cancer presented with dyspnea and anorexia. Clinical examination revealed tachypnea, tachycardia, dry cough, cachexia, and dry skin. CT scans showed bilateral pulmonary opacities and confirmed asplenia. He was admitted to the intensive care unit with an initial diagnosis of COPD exacerbation and bacterial pneumonia. He received piperacillin/tazobactam, levofloxacin, and intravenous steroids. However, the patient’s condition deteriorated, manifesting as hypotension and progressive respiratory failure, requiring mechanical ventilation and vasopressor support. Antibiotic therapy was escalated to continuous infusion of meropenem with the addition of vancomycin. Intravenous immunoglobulin (IVIG) was administered over three days. Subsequent cultures identified Klebsiella pneumoniae, leading to a revised diagnosis of septic shock secondary to OPSI. Following intensive management, including frequent bronchoscopic sputum aspirations, the patient stabilized and was extubated after two weeks. He was subsequently transferred to the general ward.
Discussion: Overwhelming Post-Splenectomy Infection (OPSI) is a critical, life-threatening condition affecting asplenic patients, with reported mortality rates exceeding 50%. It is usually caused by encapsulated bacteria, with Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis being the most common pathogens. However, infections with Enterobacteriaceae, such as Klebsiella pneumoniae, have been reported, although rare.The onset of symptoms, rapid progression, and the nature of the infecting organism necessitated an aggressive therapeutic approach. Continuous antibiotic infusion, as used in this case based on the BLING III trial, represented a nuanced clinical decision in response to a severe, life-threatening infection. Although the trial did not conclusively favor continuous over intermittent infusion for mortality reduction, the effect CI estimate included the possibility of benefit. The use of intravenous immunoglobulin (IVIG) was informed by limited evidence from case studies like those reported by Nakamura et al. The lack of robust randomized controlled trial (RCT) data for IVIG in OPSI cases poses a challenge; however, such interventions may be justified in critical situations.Given the rarity of OPSI and the practical challenges in conducting RCTs for such a condition, clinicians must often rely on observational data and case reports to guide decision-making. This case underscores the importance of a proactive, evidence-informed approach in managing asplenic patients with severe infections. It also advocates for continuing research into the effectiveness of various therapeutic strategies for OPSI, aiming to refine guidelines and improve patient outcomes.
Conclusions: This case highlights the critical importance of vigilance for Overwhelming Post-Splenectomy Infection (OPSI) in asplenic patients. The rare incidence of Klebsiella pneumoniae as a causative agent in OPSI underscores the need for broad-spectrum antibiotic coverage and consideration of adjunct treatments such as continuous antibiotic infusion and intravenous immunoglobulin.