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.