We have patient, which had c-section 35 days ago because of preeclampsia at 34 week of gestation. She was in ICU during 16 days because of gestosis complications (oliguria) and was administered hemosorption few times and she recieved meronem 10 days and after that - zyvox for 7 days.
After that she was in nephrological department during next 14 days and already was getting ready to discharge. 3 days ago fever appeared (39,5 degree centigrade), procalcitonin is 100 ng/ml, leucocytes amount 3 days ago was 30*10^9/ml, today - 0,5*10^9/ml and agranulocytosis was detected. It was an episode of low blood pressure (60/30), which was treated with dopamine. In blood Staphylococcus epidermidis is discovered.
Pulse is 130/min, breath rate 40/min, saturation with oxygen is 97%, without oxygen - 92%.
Low-lobe pneumonia and serose liquid in pleura and peritoneum were discovered.
US of kidney and urine samples are normal. US of uterus is normal. No bacteria was discovered in bacteriological investigation of urine and cervix uteri.
Now she receives vancomycin and plasmapheresis.
Where could be nidus (focal point) of infection? What additional examination should we do?
Intra-abdominal absecess should definitely be considered especially after C/S. With lower lobar pneumonia you need to consider possibility of abscess around the liver. CT, MRI or pan-abdominal ultrasound will be helpful. Will suggest G(-) coverage and will not hesitate to add coverage for anaerobics. Also keep in mind sometimes viral infection may be the cause especially HSV even without skin rash. i will pray for the mother.
I agree with above comments. She has gram negative septicaemia and all efforts should be stepped up to determine nidus of infection with CT and MRI. She requires combined antibiotics as Pravindakumar suggested. Kindly collaborate with your friendly microbiologist and ITU. She also requires Viral infections screening, echocardiography, BNP assessment to exclude myocarditis.
A multidisciplinary team involvement (ITU, microbiology, physician, nephrologist), is crucial for her survival. She could well benefit from blood and albumin transfusion and dialysis.
Good luck and best wishes for your patient
Dear colleagues! Thank you very much for your advises! All my colleagues and me very appreciate your help!
We did examinations, which you advised. You were right, we finally found Pseudomonas aeruginosa in blood in 1 probe of 3, which is resistant in majority of antibiotics, excluding amino glycosides (it has intermediate susceptibility to them). No bacteria were found in samples from cervix uteri, urine and in serose liquid, which was found in small amount in abdominal puncture. No viral infection (including CMV, HSV, EBV) were found in blood. According to susceptibility amikacin was added, as Egbert Pravinkumar suggested before.
We didn't have possibility to do CT or MRT, because patient was in ALV and now in SIPAP in ICU, so it was not possible to transport her and to do this. But we did ultrasound of liver, pancreas, kidneys, uterus (recent time - today). No changes were found. Size of uterus is 48x42x28 mm, cavity of uterus is 2-3 mm. Ovaries are normal. Some surgeons suggested, that uterus is source of infection, because it is germ-negative, and we should do extirpation of uteri, but we don't think so, because postpartum involution of uterus is close to finish, now it is 39-th day of pospartum period. Are we right?
We also did x-ray of chest and US of heart. Low-lobe pneumonia is existing and also in US of heart ejection fraction is 40%, which allow us to suspect myocarditis as well.
Patient also received plasmapheresis every day, transfusion of plasma and albumine and also pentaglobin.
In dynamics her condition is better, body temperature is 36,4 degree centigrade, WBC 3,0 * 10^9/l, granulocytes 71%.
But the main problem now is respiratory distress and acidosis. Breath rate is still 30-40 per min.
Can you advise, what else we can do? What measures can prevent myocarditis development and are we right or wrong concerning uterus?
Thank you again for your advices, they helped to us and to our patient a lot.
Good to know you had the answer. But, I would like to point out that Psudomonas is not a common pathogen and you need to consider a few possibilities be you close this case.
1. Make sure there is no accidental puncture to the colon which can be the source
2. Watch out for fistula formation between lower GI and either uterus or urinary tract
3. If the above two are not there then you need to think about contaminated instrument or facility since Pseudomonas is a water born pathogen. I have not used immunoglobulin for years and do not know whether it is going to help or not. To my knowledge most immunotherapy has not been proven very helpful in septicemia (correct me if I am wrong since I am in Pediatric field). Good luck.
Please, this lady is septic and requires to be admitted to intensive unit. As suggested by Ru-Jeng, further investigations to determine the source of Pseudomonas is necessary but not important so long as your friendly microbiologist suggests antibotic sensitive to the organism. Addition of Metronidazole is important . A CT- scan is essential + lumber puncture
Dear colleagues! Thank you very much for your advices. She slowly becomes better.
Yes, she is in ICU since she got fever. Excuse me, that I didn't mention it in my initial question.
I am delighted for you and the patient. Its good to know others care!. Well done, you are a caring doctor!
By the way , how abd exam looks like?
I think once she is stable CT abdomin still of value to exlude intraabd. collection.This is a major concern which is usually polymicrobial. I suggest if response is not satisfactory, a broad-spect . antibiotic like pip/tazo that covers other G- enterics and anaerobes would be better choice than amikicin monotherapy. will pray for her.
Dear Colleagues!
Our patient was discharged from hospital on Friday, 27 of December.
The Head of our hospital, our staff and myself are very grateful for your brilliant advises, which helped us a lot and allowed us to safe life of this young women. Thank you very much!
Happy New Year! May it bring to you joy and happiness!
Excellent!! Outcome will certainly make patient and who contributed to her care happy. Have a fabulous new year.
Good to know she was discharged in good condition. Please follow-up proactively . Thanks
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