Case of the Week
Pericarditis Caused by Enterococcus faecium with Acute Liver Failure Treated by a Multifaceted Approach including Antimicrobials and Hemoadsorption
Thomas Köhler,1 Mathias W. Pletz,2 Simon Altmann,1 Carmen Kirchner,3 Elke Schwier,1 Dietrich Henzler,1 Günther Winde,3 and Claas Eickmeyer1 | 1Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, Herford, Germany | 2Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany |3Department of General and Visceral Surgery, Thoracic Surgery and Proctology, Ruhr University Bochum, Klinikum Herford, Herford, Germany | Case Reports in Critical Care 2021; epub
04/14/2021
New!Peer Reviewed Published DataReduction in catecholaminesSafetySeptic ShockImprov. resp functionAnticoagulation CitrateBilirubinCase of the weekCase reportCritical CareCRRT (pre or post filter)Inflammatory parametersLiver failureMOF
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Summary
CoW 15/2021 – This case reports on a 29-year-old woman with a history of Crohn’s disease and cachexia, who was hospitalized due to painful diarrhea and unintentional weight loss of 13 kilograms over the previous three weeks caused by a mechanical ileus.
Case presentation
Transfer to the intensive care unit (ICU) occurred 2 weeks later because of increasing somnolence, impaired gas exchange and hemodynamic instability. She quickly required high dosage of norepinephrine (up to 1.56?µg/kg/min)
Laboratory diagnostics revealed significantly altered hepatic (albumin 23.8?g/l, gamma-GT 118?U/l, alkaline phosphatase 142?U/l, cholinesterase 1814?U/l) and elevated inflammatory parameters (C-Reactive Protein CRP 194.8?mg/l, and procalcitonin PCT 59.80?µg/l)
The Sequential Organ Failure Assessment (SOFA) score was 6
The severity of the clinical picture demanded an exploratory laparotomy for source control. Intraoperatively, a perforation with local peritonitis was found in the lower abdomen. A right hemicolectomy, partial resection of the small bowel, and side-to-side anastomosis were performed. Histology revealed massive chronic inflammation of the terminal ileum, typical of Crohn’s disease
Preoperatively started antibiotic therapy with piperacillin/tazobactam was continued for four days according to the resistogram (Providencia stuartii, Escherichia coli, and anaerobic bacteria)
Blood cultures taken on ICU admission were negative
The patient was treated with differentiated volume and catecholamine therapy
As she still required high doses of norepinephrine, a combination of continuous renal replacement therapy (CRRT) and adjunctive CytoSorb hemoadsorption therapy was initiated (1st treatment cycle with 3 consecutive CytoSorb treatments) resulting in rapid hemodynamic stabilization and reductions in inflammatory parameters and bilirubin (see results section)
Four days after the operation and after CytoSorb discontinuation, the patient’s condition started to worsen rapidly again with tachycardia, hypotension, and fever up to 39.0°C, as well as diminishing oxygen saturation levels
The patient had to be reintubated and norepinephrine administration had to be re-initiated for hemodynamic stabilization (1.09?µg/kg/min)
In the next hours, hemodynamics stabilized while diuresis resumed spontaneously and renal replacement therapy could be stopped shortly after
A chest X-ray performed the same day revealed a pleural effusion
In search of an infectious source, samples (pleural fluid, two sets of blood cultures and bronchoalveolar fluid) were sent to microbiology but all proved negative
Abdominal and chest CT scan revealed an intact anastomosis but showed multiple dense foci inside the lungs
Despite the negative microbiology, the decision was made to intensify antibiotic therapy by escalation to meropenem
Liver function testing indicated severe liver insufficiency
In addition, a subsequent CT scan confirmed severe, previously unknown, changes consistent with emphysema (bullae) in the lungs which further compromised gas exchange
Over the next 9 days, both chest X-ray and CT scans indicated morphological improvements
However, the patient’s condition rapidly deteriorated once more, now presenting as a multiple organ dysfunction syndrome (SOFA score 12)
Inflammatory marker levels were clearly increased and the patient became anuric, while FiO2 levels required an increase up to 100% and liver function was still severely impaired
The hypothesis was septic shock syndrome, and blood culture samples were taken; however, these showed no bacterial or fungal growth
As the patient required CRRT at this time point, the decision was made to re-apply the CytoSorb system in order to attenuate the hyperinflammatory response and to eliminate liver metabolites, such as bilirubin, ammonia, and bile acids in the context of sepsis-associated acute liver failure (2nd treatment cycle with 13 consecutive CytoSorb treatments)
While under CytoSorb treatment, an emergency re-laparotomy was performed excluding any intra-abdominal source of sepsis. However, echocardiography revealed a significant increase in pericardial effusion and pericardial tamponade was diagnosed. The patient underwent a pericardial tap, and a drain was inserted. Enterococcus faecium was identified in the pericardial fluid and also in all blood cultures, intra-abdominal, urine and tracheal fluids.
All strains proved to have equal resistance patterns suggesting a common origin that was most likely the ruptured ileum
Based on these findings, an antimicrobial chemotherapy supplemented by tigecycline and the antifungal caspofungin was considered appropriate
Treatment
1st treatment cycle: 3 consecutive CytoSorb treatments were performed for a total of 73 hours
2nd treatment cycle: 13 consecutive CytoSorb treatments were run for a total duration of 346 hours (14 days)
CytoSorb was performed in conjunction with CRRT run in continuous veno-venous hemodialysis (CVVHD) mode
Anticoagulation: citrate
Measurements
Hemodynamics and norepinephrine requirements
Inflammatory parameters (interleukin – IL-6)
Parameters of liver dysfunction including bilirubin, ammonia, severity of hepatic dysfunction score (Model for End-stage Liver Disease [MELD]-Score)
Ventilation
Renal function
Results
1st treatment cycle (3 treatments)
CytoSorb therapy was associated with a rapid stabilization in her hemodynamic situation (norepinephrine down to 8.3% of the maximum initial dose)
IL-6 levels decreased from ~850 pg/ml to ~140 pg/ml during the 3 CytoSorb treatments
Treatment was also associated with a reduction in bilirubin (from 1.2 to 0.3 mg/dl) as well as an improvement in MELD score from ~27 to ~11 points
Extubation was possible on the day of CytoSorb cessation
2nd treatment cycle (13 treatments)
Throughout the 2nd treatment cycle, there was a reduction in vasopressor requirements down to 16.9% of the maximum initial dose
The hyperinflammatory response declined as evidenced by a decrease in IL-6 plasma concentrations from ~550 pg/ml to ~150 pg/ml and a consistent improvement over the course of the following days
Furthermore, treatment resulted in a normalization in bilirubin levels accompanied by an improvement in MELD score form ~26 to ~10 points
Invasive ventilation could be switched to assisted ventilation
Onset of spontaneous diuresis occurred at the end of the 2nd treatment cycle
Patient Follow-Up
As norepinephrine requirements were minimal, CytoSorb therapy was discontinued
Following discontinuation of CytoSorb treatment, the sedation rate could be gradually reduced and the patient regained consciousness with continuous improvement in her mental state
To facilitate weaning, a tracheotomy was performed
In the meantime, the patient’s overall clinical condition improved accompanied by a reduction in SOFA score to 6
Five days later, E. faecium was cultivated from the tip of the central venous catheter under continued antimicrobial therapy with tigecycline. The catheter was removed and tigecycline was changed to linezolid (600?mg twice daily)
Liver function testing 8 days after CytoSorb discontinuation showed a stable, but still medium-gross restricted hepatic function
After further improvement, the patient was discharged in a stable clinical condition from the ICU to the normal ward 53 days after her initial admission
Conclusion
This is the first detailed description of an E. faecium pericarditis in a patient with complex pathophysiological changes caused by a multitude of different chronic (Crohn’s disease, cachexia) and acute diseases (septic shock with multiorgan failure in bacterial pericarditis), requiring multilayered interdisciplinary intervention including anti-infective therapy, hemoadsorption with the CytoSorb cartridge, and dynamic liver function testing
This interdisciplinary intensive care therapy approach in combination with CytoSorb as an individual adjuvant treatment concept allowed control of the hyperinflammation and clear decreases in the vasopressor requirements
The combination of the adsorption and elimination of bilirubin and bile acids, the modulation of involved cytokines, and the reduction of excess ammonia levels via parallel renal replacement procedure allow a bridge in time until functional recovery or orthotopic liver transplantation. CytoSorb therefore represents a promising, easy to perform method for liver support.
