It is a hot afternoon in August when a 58-year-old man is brought to the emergency room of the University Hospital Hamburg by his wife. He has felt uncomfortable for about 12 hours, suffering from watery. On the same day he had started to feel feverish and unusually tired.
When he arrived, the patient is conscious, but seems tired and sweaty. His vital parameters are as follows:
In the physical examination, there is a slightly absorbed abdomen with diffuse pressure sensitivity, without defense tension or peritonism. Jaundice is not immediately recognizable; The patient’s skin and extremities have no or lesions. The abrasion of the heart and lungs is inconspicuous.
The patient suffers from alcohol-related cirrhosis (Child-Pugh B, no previous encephalopathy), type 2-diabetes mellitus with poor and arterial hypertension. Medicines: propranolol, metformin. No known allergies. The couple has not yet taken a summer vacation (just a few weekend trips to the nearby coast). They reported a trip to the Canary Islands last December.
First examinations
Table of Contents
- Bluttests: WBC 12.500/µL, Hb 13,6 g/dL, Thrombozyten 92.000/µL, CRP 168 mg/L, Kreatinin 1,4 mg/dL, Bilirubin 2,2 mg/dL, INR 1,6, Glukose 278 mg/dL.
- Arterial blood gas analysis: PH 7.36, lactate 2.9 mmol/l.
- Electrolyte: Light hyponatremia (Na 131 mmol/l).
- EKG: Sinustachycardia at 105 rpm, QTC 460 ms, no ischemic changes.
- X -ray of the chest: normal.
- Abdominal ultrasound: cirrhotic liver with moderate splenomegaly, no ascites.
First impression in the emergency room
The team suspects acute infectious gastroenteritis, most likely due to food, possibly complicated by one in connection with cirrhosis. The patient was hydrated with intravenous saline solution and received paracetamol against the fever. He was included in the observation station for monitoring.
Clinical course
In the first few hours, the patient is treated against on the observation station with intravenous liquids (2 l crystalloids over 4 hours) and paracetamol. The work diagnosis is still infectious gastroenteritis, justified by acute diarrhea, abdominal cramps, moderate leukocytosis and the lack of alarming abdominal or systemic symptoms. At this point, no microbiological cultures are arranged.
Six hours later, the nurse finds that the patient is increasingly sleepy, sweaty and gorge. His new vital parameters are:
- Blood pressure 88/55 mmHg,
- Heart rate 122 rpm,
- Tempered at 39,4 ° 100;
- SPO₂ 93 % in room air.
The urine excretion has decreased significantly.
Repeated laboratory results show a significant deterioration:
- WBC 18.700/µL, Thrombozyten 62.000/µL, Bilirubin 3,8 mg/dL, Kreatinin 2,1 mg/dL, CRP 320 mg/L und Laktat 5,5 mmol/L.
- The arterial blood gas analysis confirms metabolic acidosis (PH 7.30 – HCO₃⁻ 18 mmol/l).
A repeated ECG shows a persistent sinusachycardia with non-specific ST-T anomalies; No arrhythmias are observed. The highly sensitive troponin is slightly increased at 45 ng/l, which is interpreted as a needy chamber. The X -ray of the remain unchanged.
At this point, the suspected diagnosis of suspected gastroenteritis changes to sepsis unclear cause. Blood cultures are immediately removed and a stool sample for bacteriological examination is sent in, although the patient has no further bowel movements at that time.
At this point, the team primarily assumes a severe intestinal infection in a cirrhotic patient and expects cultures to show frequent food -related pathogens such as Salmonella Enteritidis or Campylobacter jejuni. It starts with an empirical intravenous with Piperacillin-Tazobactam (4.5 g every 8 hours) and the patient moved to the intensive care unit. A noradrenaline infusion begins to maintain a medium arterial pressure (map) over 65 mmHg.
During the night, about 4 hours after the briefing to the intensive care unit, new skin changes occur under close monitoring: a rapidly increasing, extremely painful violet area on the left lower leg, which develops into hemorrhagic to large hemorrhagic within a few hours. The skin around the lesion is excited, warm and erythematous.
Surgeons are consulted for urgent assessment because there is suspicion of necrotizing fasciitis. At the bedside, they confirm severe pain that is in no different ratio with the physical findings, as well as a rapidly spreading necrosis.
The patient is immediately brought to the operating room to carry out a surgical examination. An extensive edema of the subcutaneous tissue and the fascia with necrosis, although the muscle tissue appears intact.
Large wound cleaning of the non -viable tissue is carried out. Several samples are removed for the microbiological analysis, including cuts of the bubbles, in the hope of isolating typical necrotizing soft tissue pathogenes such as streptococcus pyogenes, staphylococcus aureus or anaerobians including Clostridium species. A vacuum sealing system (VAC) is used for temporary wound care.
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