Case Description:
The patient is a 40-year-old gentleman without significant past medical history who presented to the hospital for worsening shortness of breath, abdominal distension and lower extremity swelling over the past few days. Patient had extensive history of alcohol use but does not have confirmed diagnosis of cirrhosis.
Physical exam was significant for and abdominal exam with a distended abdomen. Respiratory exam was significant for lung sounds diminished bilaterally, worse in the left lower lobe. Cardiovascular exam significant for tachycardia. Neurological exam positive for altered mental status not alert and oriented to person, time or place which is normal at baseline. Patient had initial hypotension with BP 75/45, other vital signs of respiratory rate of 34, heart rate 150, temperature 36.5, saturating 83% on room air. Patient had a diagnostic and therapeutic paracentesis was also done (2.3 L), with paracentesis labs not showing any SBP. Patient required intubation for persistent altered mental status with concerns for maintenance of airway. Initial labs were significant for hyponatremia, hypokalemia, hypomagnesemia, high anion gap metabolic acidosis primarily driven by lactic acidosis, acute kidney injury, direct bilirubinemia with normal alkaline phosphatase (hypoalbuminemia with INR of 2.2; AST 187/ALT 15), hypoglycemia, leukocytosis with neutrophilic predominance, anemia with hemoglobin of 12.7. Chest x-ray was significant for reticular and airspace opacities in the right middle and lower lobe with left-sided pleural effusion. CT of the abdomen and pelvis was done which showed right lower lobe consolidation, with large left sided pleural effusion and ascites. Patient was started on vaso-pressors. Given 1 dose of piperacillin-tazobactam was also given for concern of septic shock on initial admission. Thiamine 100 mg intravenously was also given.
Blood cultures were drawn before antibiotics were given, which resulted positive for Acinetobacter baumannii in the blood. Suspected source due to chest x-ray was pneumonia. Antibiotics were escalated to Vancomycin and Cefepime from piperacillin-tazobactam before blood cultures resulted. Cefepime was escalated to Meropenem once cultures resulted positive for Acinetobacter baumannii infection. Initially, the patients’ vaso-pressor requirements decreased as norepinephrine was titrated down on vancomycin and meropenem. Antibiotics were deescalated to Unasyn as sensitives resulted forAcinetobacter baumannii infection. Yeast grew a few days after fluid was collected, micafungin was started. Within the next 24 hours, the patient’s vaso-pressor requirement increased from norepinephrine to additional vasopressin and phenylephrine for blood pressure support. Furthermore, epinephrine was added as a fourth pressor as the patient required CRRT due to AKI. Patient became anuric, was started on CRRT and the patient succumbed to the septic shock secondary to theAcinetobacter baumannii infection and the peritoneal yeast infection.