Fatal Delayed-Onset Overwhelming Post-splenectomy Infection 26 Years After Splenectomy for Immune Thrombocytopenic Purpura.

Overwhelming post-splenectomy infection (OPSI) is a rare but life-threatening complication that can occur at any time after splenectomy, most often involving encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. We report the case of a 36-year-old Caucasian female, 26 years post-splenectomy for immune thrombocytopenic purpura, who presented with flu-like symptoms and altered mentation. On arrival, she was hypotensive, tachycardic, febrile, and hypoglycemic with purpura fulminans and conjunctival injection. She rapidly progressed to septic shock requiring vasopressors, disseminated intravascular coagulation, and acute respiratory failure necessitating mechanical ventilation. Blood cultures revealed Streptococcus pneumoniae bacteremia, and the pneumonia panel identified non-COVID-19 coronavirus, adenovirus, Haemophilus influenzae, and Staphylococcus aureus. Her course was complicated by acute kidney injury requiring continuous renal replacement therapy and bilateral lower limb ischemia. Despite aggressive management, she deteriorated rapidly and died within 48 hours of admission. This case underscores the critical nature of OPSI and purpura fulminans in asplenic patients and emphasizes the importance of prompt recognition and treatment. While vaccination against encapsulated organisms reduces risk, vaccination failures remain possible. Thorough patient education regarding prodromal symptoms and the integration of prophylactic measures, including early antibiotic initiation, are essential. The high mortality associated with OPSI, even decades after splenectomy, highlights the necessity of ongoing preventive strategies, vigilant monitoring, and rapid intervention to mitigate fatal outcomes.