|LETTER TO EDITOR
|Ahead of print publication
Bilateral empyema caused by Acinetobacter Baumanii leading to septic shock and death – A case report
P Shihabudheen1, Shamsudeen Moideen2, NA Uvais3
1 Department of Medicine, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
2 Department of Internal medicine, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
3 Department of Psychiatry and Health Research, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
|Date of Submission||17-Nov-2022|
|Date of Decision||12-Dec-2022|
|Date of Acceptance||13-Dec-2022|
|Date of Web Publication||24-Jan-2023|
Department of Psychiatry and Health Research, Iqraa International Hospital and Research Centre, Calicut, Kerala
Source of Support: None, Conflict of Interest: None
Acinetobacter baumannii is a significant pathogen, often found to be associated with sepsis, wound infections, and pneumonia, in immunocompromised and hospitalized patients. We report the case of a male patient who presented with bilateral empyema due to A. baumannii infection and his treatment course.
A 38-year-old male patient, who is on rehabilitatory care for traumatic spinal cord injury with tetraplegia came to the emergency department with complaints of decreased urine, vomiting, and feverishness following suprapubic catheterization, and suddenly became unresponsive and pulseless. He was given cardiopulmonary resuscitation for 2 min and Return of spontaneous circulation (ROSC) was attained. He was managed initially with inotropic support and IV fluids. His laboratory investigations revealed severe acidosis (serum lactate: 9.6 mmol/L). ECG and echocardiography showed features of apical Myocardial infarction and High-sensitivity Troponin [MI and TropI (HS)]was high (29080 ng/dl). He was intubated and mechanically ventilated in view of severe hypotension and acidosis. A contrast-enhanced computed tomography scan of the abdomen showed only mild ascites and bilateral mild pleural effusion. He was started on antiplatelets, heparin infusion, and inotropic supports continued. His serum procalcitonin done on the second day of admission was >200 ng/ml (cutoff >10.0 in septic shock). Antibiotic, piperacillin/tazobactam, was started after taking two samples of blood cultures from two different sites along with a urine culture. Injection of hydrocortisone and injection of thiamine and ascorbic acid as per Marik protocol were also initiated. From the 3rd day onward, the patient started showing improvement in blood pressure and urine output. However, he persisted to have relatively high lactate, neutrophilic leukocytosis, and thrombocytopenia. Heparin was stopped considering the bleeding risk. The culture report showed the growth of third-generation cephalosporins-sensitive Escherichia More Details coli. On day 6, although he was afebrile, investigations showed features of bone marrow suppression and coagulopathy in spite of Vitamin K injections. A repeat chest X-ray was done which showed bilateral pleural effusion with the right side having moderate-to-massive effusion. A diagnostic tap followed by implantable cardioverter defibrillator (ICD) insertion was done on both sides on the same day itself. Around 1.5 L of pleural fluid was drained from both sides and bacterial cultures were sent. Considering the high serum n procalcitonin level (55.22 ng/ml) injection of meropenem was started. However, the patient deteriorated rapidly in the form of hypoxia and severe hypotension. A repeat chest X-ray showed pneumothorax on the left side, for which another ICD was inserted on the left side. His hypoxia improved, but hypotension worsened over hours requiring triple vasopressor support and he succumbed the next day morning. Two days after, culture reports of pleural fluid from both sides showed the growth of Extremely drug-resistant (XDR) A. baumannii, which was sensitive to collision and intermediately sensitive to minocycline and tigecycline and was resistant to all other antibiotics.
A. baumannii has become a common nosocomial pathogen, affecting especially patients receiving treatment in the intensive care unit setting. It is a Gram-negative, strictly aerobic, nonfastidious, nonmotile, catalase-positive, oxidase-negative, and non-fermentative coccobacillus. The accumulating evidence suggests that it can cause serious infection and contributes substantially to the considerable mortality of this population, as in our case. Past studies have shown various complications following A. baumannii infection including septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, systemic or disseminated infection, multiorgan failure, and death. However, A. baumannii infection presenting with bilateral empyema leading to septic shock and death is a very rare presentation. Early administration of appropriate antimicrobial therapy, removal of the source of infection, provision of advanced supportive care, along with strict infection control measures, are essential in the management of A. baumannii infection.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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