Case of the Week
Hemoadsorption as part of a multimodal therapy concept to treat Capnocytophaga sepsis with thrombocytopenia and multiple organ failure
Kreutz J, Choukeir M, Chatzis G, Schieffer B, Markus B. Int Journal Art Organs 2022; epub
11/30/2022
MyoglobinNew!Other indicationsPeer Reviewed Published DataRhabdomyolysisSafetySeptic ShockAnticoagulation CitrateCase of the weekCase reportCritical CareCRRT (pre or post filter)Inflammatory parameters
Link to sourceDownload documentDownload document
Summary
CoW 40/2022 – This case reports on a 68-year-old male with known arterial hypertension, who presented at the hospital by ambulance following severe deterioration of his general condition including fever up to 39°C, oliguria and repeated vomiting over the recent days.
In this case report a 68-year-old presented at the hospital following a severe deterioration in his general condition, including fever up to 39°C, oliguria and repeated vomiting for a couple of days following a dog bit to his right foot whilst on holiday. On admission, the patient showed pronounced marbling and cyanosis to all extremities and ears. The reddened bite wound to the second toe did not appear infected so there was no medical or surgical intervention at this time. Despite standard therapy including antibiotics and multiple blood products he developed septic shock with acute renal failure, liver dysfunction, cognitive dysfunction and respiratory deterioration so was started on continuous renal replacement therapy (CRRT), and eventually intubated and ventilated. Given the patients hyperinflammatory condition a CytoSorb hemoadsorber was additionally integrated into the CRRT circuit. In total 4 adsorbers were used during this 1st therapy interval (changed every 12 hrs). CytoSorb was then stopped for 24 hrs as he improved clinically, however, due to a relapse in his clinical condition, CytoSorb was then restarted for another 5 treatment sessions for 24 hours each (2nd therapy interval). All of the applied therapeutic measures led to rapid clinical stabilization, control of the hyperinflammatory situation, and improvement in his neurological status. The therapy was well tolerated with no complications encountered. The patient was able to be extubated after 3 days of mechanical ventilation and he was finally able to be transferred to a rehabilitation unit in a stable condition after a total hospital stay of 32 days. This is the first clinical case describing the successful application of a multimodal treatment approach including extracorporeal blood purification therapy in a patient with septic shock, acute renal failure and severe thrombocytopenia with signs of DIC and TMA due to Capnocytophaga infection following a dog bite.
Case presentation
Two days previously, he had returned from a vacation where he had had a dog bite to his right foot and subsequently complained of chills, sweating, tachycardia, and general malaise
On admission, the patient showed pronounced marbling to all extremities and ears with cyanosis of his extremities. The reddened bite wound to the second toe did not appear infected so there was no need for any medical or surgical intervention at this time
Subsequent chest X-ray examination for a focus proved inconclusive
Echocardiography revealed a mild to moderately reduced systolic function, which was consistent with septic cardiomyopathy
In addition, an infection-triggered atrial fibrillation was detected during this acute phase
Laboratory diagnostics revealed clearly elevated infection parameters (leucocytes 33 G/l, procalcitonin (PCT) >100 µg/l, C-reactive protein (CRP) 298 mg/l, interleukin (IL)-6 1866 pg/ml) and in light of all of these findings, the patient was diagnosed with sepsis progressing to septic shock
In addition, his coagulation status was markedly deranged (thrombocytes 6 G/l, Quick 22%, International Normalized Ratio [INR] 3.1, activated Partial Thromboplastin Time [aPTT] 112 sec) consistent with disseminated intravascular coagulopathy (DIC) and thrombotic microangiopathy (TMA), resulting in the administration of fresh frozen plasma (FFP) and platelet concentrates to stabilize his coagulopathy
Also, over time, a red blood cell transfusion was needed due to considerable volume administration of blood products leading to dilution, low hemoglobin (13.8 g/dl) and signs of hemolysis as evidenced by clearly increased levels of lactate dehydrogenase (3164 U/l)
Following detection of intracellular and extracellular rod-shaped bacteria in the initial differential blood count and in the blood smear with suspected Capnocytophaga canimorsus infection, anti-infective therapy was initiated with ampicillin/sulbactam and clarithromycin. The antibiotic regimen was then escalated to piperacillin/tazobactam (18 g/24h) and levofloxacin (500 mg twice daily). As infection parameters continued to increase further, antibiotic therapy was again escalated to imipenem (4 g per day) on day 2
Additionally, the patient received 2 units of FFP every 6 hours
In the context of increasing retention parameters (creatinine 4.34 mg/dl) and oliguria (24 hours diuresis 150 ml) under ongoing volume resuscitation, the decision was made to initiate continuous renal replacement therapy (CRRT)
Furthermore, high-flow oxygen therapy was started because of assumed cardiac decompensation with incipient pulmonary edema and his significantly reduced general condition
Radiological examination, however, only revealed a slight congestion with bilateral pulmonary infiltrates
The patient also exhibited signs of liver dysfunction (aspartate aminotransferase [AST] 1094 U/l, alanine aminotransferase [ALT] 365 U/l, lactate dehydrogenase [LDH] 3164 U/l, bilirubin 2.89 mg/dl) as well as increased creatine kinase (418 U/l) and myoglobin levels (1674 µg/l)
Laboratory diagnostics further revealed severe hyperlactatemia (6.3 mmol/l)
Over time, the patient showed progressive respiratory deterioration whilst on high-flow oxygen therapy and so he was switched to non-invasive oxygen therapy
However, due to clearly reduced vigilance (Glasgow Coma Scale [GCS] 8) and incipient respiratory insufficiency with progressive metabolic acidosis (pH 7.34), the patient eventually had to be intubated and mechanically ventilated on the same day
During this episode of respiratory decompensation, norepinephrine and dobutamine infusions were required briefly
Given the patients hyperinflammatory condition in the context of septic shock, a CytoSorb hemoadsorber was additionally integrated into the CRRT circuit
After clinical improvement under CytoSorb treatment, therapy was discontinued. However, due to a recurrence in clinical deterioration, hemoadsorption therapy had to be reinstituted for a second therapy interval
Treatment
The patient received a total of 9 CytoSorb hemoadsorption therapy sessions over the following 8 days (4 adsorbers during the first two days changed every 12 hours [1st therapy interval], pause interval of 24 hours, thereafter another 5 treatment sessions for 24 hours each [2nd therapy interval])
CytoSorb was used in conjunction with CRRT run in continuous veno-venous hemodiafiltration (CVVHDF) mode
Blood flow rate: 100 ml/min
Anticoagulation: citrate
Measurements
Inflammatory parameters
Myoglobin
Lactate
Neurologic status
Results
During the course of combined hemoadsorption and renal replacement therapy treatment, stabilization in his overall clinical condition was noticed accompanied by clear control of the hyperinflammatory situation as evidenced by a significant decrease in inflammatory parameters by the end of the treatment cycle (e.g. PCT from >100 to 1.2 µg/L after CytoSorb treatment, CRP from 298 to 94 mg/L. IL- 6 levels decreased from 1866 to 833 pg/ml within one day of CytoSorb initiation)
Plasma concentrations of myoglobin could be reduced from 1674 to 108 µg/L
Lactate decreased from 6.3 to 0.9 mmol/L during the course of the 9 therapy sessions
Combined CRRT+CytoSorb therapy was further associated with neurological improvement finally resulting in swift extubation after 3 days of mechanical ventilation
Patient Follow-up
On the 7th day on the intensive care unit, blood cultures, which have already been preserved at the time of admission, yielded the Gram-negative bacillus Capnocytophaga canimorsus
Markers of inflammation increased after discontinuation of imipenem most probably in the context of a concomitant pneumonia, requiring escalation of antimicrobial therapy to vancomycin plus ceftazidime
His reduced left ventricular function recovered during his inpatient stay
With improved urinary output, CRRT was discontinued
Of note, during his hospital stay, the patient received prednisolone (100 mg/d) for 3 days as additional therapy as well as a total of 51 units of FFP
He was finally transferred to a rehabilitation unit in a cardio-respiratory stable general condition after a total hospital stay of 32 days
At the time of discharge, the patient still had dry necroses on two toes of both feet which will probably lead to amputation over time
Conclusion
This is the first clinical case describing the successful application of a multimodal treatment approach including extracorporeal blood purification therapy in a patient with septic shock, acute renal failure, and severe thrombocytopenia with signs of DIC and TMA due to Capnocytophaga infection following a dog bite
Application of therapeutic measures including antibiotic therapy, mass transfusions, CRRT and CytoSorb hemoadsorption therapy was associated with rapid clinical stabilization, control of the hyperinflammatory situation, and improvement in his neurological status
The therapy was well tolerated with no complications encountered
This case supports the clinical recognition of severe Capnocytophaga infection that can lead to critical conditions even in immunocompetent patients.
