PGY3 Tyler Degener presented a case of a 40 y/o F with history of SLE complicated by APLS and AIHA s/p splenectomy and HCV presents with 1 day of epigastric abdominal pain. She states that the pain started about 6 hours after eating breakfast (several eggs left on counter for few days), epigastric in location, and throbbing in nature. Pain not associated with PO intake or position. Reports subjective fevers, diaphoresis, NBNB nausea and vomiting the next morning. She denies diarrhea, constipation, bloody stools, dysuria, vaginal discharge. Of note, she lacerated her R foot on piece of broken glass 2 weeks prior to presentation, for which she went to OSH ER where had stitches placed and is healing well. Home medications include Belimuab qweek, hydroxychloroquine qday, prednisone qday, enoxaparin 80mg qday and azathioprine qday. Social history pertinent for no recent travels, lives at home with husband and cat. Vitals significant for temperature eof 39C, HR 151, RR 24, BP 105/58 and satting 98% on RA. Exam with tachycardia, tachypnea, abdomen tender to palpation at epigastric region and R foot with healing laceration.
CBC: WBC 12.6 > Hb 11.8/Hct 36.3 <Plt 331
Na 142/K 3.8/Cl 106/HCO3 22/BUN 18/Cr 0.54 <Glucose 114
ALP 87>T.protein 6.5/Albumin 3.9/AST 45/ALT 46/Tbili 1.2/DBili <0.4
Coags: PT 14.8, INR 1.17
Lipase 54 U/L (normal 13-60)
BNP 2819 (normal <125)
- Lactate 2.2
- COVID-19 negative
- UA with 30 proteins, negative leuk, negative nitrite
- UCx negative
- Stool culture negative
- Stool O&P negative
- C diff negative
- Hep C VL was not detected
- TTE with EF of 38%, mild diffuse hypokinesis, no valvular dysfunction
- BCx was initially no growth for the first 2 days
- D-dimer 0.45 (normal <0.5)
- LDH 211 U/L
- Haptoglobin 84 mg/dL
- Abs Retic count 26 x 10^9
- CRP 212 mg/L (normal <5)
- ANA 1:80
- dsDNA negative
- C3 60 (normal 90-180)
- C4 6.7 (normal 10-40)
US Abdomen negative for cholecystitis. No bile duct dilatation.
CT A/P showed diffuse gallbladder wall thickening without gallstones. Hepatomegaly, periportal edema, caudate lobe hypertrophy and L liver lobe volume redistribution consistent with history of chronic liver disease. There is also areas of heterogeneous hypoenhancement in the L liver lobe which are likely secondary to ischemia given the patient’s history of hypotension.
Patient developed septic shock on hospital day 2 and had to be upgraded to the MICU on peripheral levophed while awaiting culture results. BCx on day 2 resulted in gram variable rods and finally speciated into Capnocytophaga canimorsus on day 4 of hospitalization. Patient also remembered that her cat had bit her on the R thumb 3 days prior to admission.
Treatment: Patient was initially started on Ceftriaxone/Flagyl on admission and broadened to meropenem and vancomycin after developing septic shock. She was started on stress dose steroids 100mg Q8H. After BCx results, antibiotics were downgraded to Ceftriaxone.
Take home points:
- Gram variable rod is an organism that has a mixed gram positive and gram negative on staining. Some examples include Clostridium, Bacillus, Acinetobacter and Capnocytophaga. It often takes a bit longer to ID in the micro lab.
- C. canimorsus is a rare cause of fulminant sepsis in those bitten by an animal (usually dog but can be cat) with immunocompromised hosts at higher risk. For prophylaxis, in an animal bite, can give amoxicillin-clavulanate x5 days.
- Asplenic patients have higher risk of infection from encapsulated organisms such as Strep pneumo, H. flu, N. meningitidis. The presentation may be mild and not appear toxic but can progress quickly to fulminant disease. Therefore, any febrile illness in an asplenic patient should warrant broad spectrum antibiotics and prompt medical evaluation.
- In patients on chronic steroid use to underlying chronic disease, it is important to give stress dose steroids when the patient is ill such as in sepsis or perioperatively.