SEVERE SEPTIC SHOCK DUE TO SOFT TISSUE INFECTION

ESIM 2014

A. BAHAR KELEŞOĞLU, MDHACETTEPE UNIVERSITY FACULTY OF MEDICINE INTERNAL

MEDICINE DEPARTMENTANKARA - TURKEY

CASE PRESENTATION

57 y , male Admission to emergency department with fever and

erythema and bullous lesions on the right lower limb thatstarted with a local erythema 1 day before .

On admission Hypotension, fever, dyspnea Septicshock protocole + Entubation ICU

Carbapenem + Teikoplanin + Clindamisin started

CLINICAL HISTORY 2000 Gastric malignancy(+) Subtotal gastrectomy

+ chemotherapy Cured Chronic hepatitis B(+) No medication 2013 Nephrotic syndrome due to

membranoproliferative glomerulonephritis tip 1 Pulsesteroid

Current medication: Lansoprazole 1X1Essential amino acids 3X1Prednizolone 2X 32 mgFurosemide 2X40 mgSpiranolactone 1X1 Fluoxetine 1X1

PHYSICAL EXAMINATION

T:39.7°CHR:124/minBP:80/50mmHg RR:34/minEntubated patient, Glasgow coma scale: 9Erythema, bullous lesions on the right flank and leg (+)Pitting edema ++++/++++No other positive sign

LABORATORY FINDINGS

ESR: 30 mm/hr (0-20) CRP: 21.2 mg/dL (0-0.8) Procalcitonin: 605 ng/mL Lactate: 5 mMol/L ALT:14(0-40) AST:21 (0-35) Blood urea nitrogen: 119

mg/dL Creatinin: 1.81 mg/dL Na /K: 133 / 3.14 mEql /dL Albumin: 1.65 g/dL INR:1.28 (0.86-1.2) aPTT:39.1 (27-38)

Fibrinogen:532 (219-403) D-dimer:3.09 (0-0.48) Hgb:12.1 g/dl (11.7-15.5) WBC:2000/mm3 (4100-

11200) Plt:84,000/mm3 (159,000-

388,000) Peripheral smear: True thrombocytopenia Hepatitis B virus

load:261.900 copy/mL C3- C4 low Autoantibodies (-)

DIFFERENTIAL DIAGNOSES??

Steven Johnson’s Syndrome Vasculitis Drug Eruption Meningococcemia Soft tissue infection

ICU:

All cultures are taken – including deep tissue culture Intensive hemodynamic support and broad spectrum

antibiotic therapy were administered Anuria, acute renal disease (creatinin: 4.18 mg/dL,

hyperkalemia, hyperphosphatemia )and hypervolemiadeveloped Hemodialysis

Due to the DIC and pancytopenia RBC , FFP , Thrombocyte replacements were done

Lamivudin therapy started. Punch biopsy: Vasculitis, inflammation and bacterial

colonies

Fever continued but other vital signs came to normal On the abdominal chest tomography Multiple

microabscesses on the hepatic parenchyma On the day he was planned to go to surgery for

debridement , septic shock and acute respiratorydistress syndrome secondary to sepsis developed.

CK: 302 U/L , miyoglobin:1541 ng/mL 6 hours hemodialysis was done Cardiac arrest -- > Exitus

Post-mortem culture results: Blood , central venous cathater , bronchoalveolar

lavage and deep tissue cultures:Acinetobacter baumaniiOnly colistin and amicasin sensitive

Diagnosis: Necrotizing fasciitis due to Acinetobacterbaumanii enfection

TAKE HOME MESSAGE Necrotizing fasiciitis is an uncommon soft tissue infection,

associated with a high morbidity and mortality. Its early recognition is often difficult and has an effect on

survival. There are 2 subtypes:1) Polymicrobial form: The most common (55-75%)2) Associated with Group A streptococcus infection Predisposing factors: Diabetes, immunsupression, obesity,

malnutrition and peripheral vascular disease. Acinetobacter baumanii is rarely associated with necrotizing

fasiciitis. Therapeutic management: Rapid and extensive surgical

debridement ( the most important), antibiotic therapy,hyperbaric oxygen therapy, reconstructive surgery andpostoperative rehabilitation.

THANKS FOR YOUR PATIENCE