A 69-year-old male patient with a history of one year hypertension and 20 years lumbar disc herniation, presented with ten days pain of left lower limb and fever without certain reason, first admitted to local hospital and diagnosed with lumbar disc herniation, was transferred to the ICU at Qilu hospital of Shandong University after having fever up to 39.2℃ on 9 June 2019.
The CT of pelvis and lower limbs from local hospital showed extensive subcutaneous pneumatosis and soft tissue edema of left lower limb and retroperitoneal space involving iliac fossa and inguinal region(Fig. 1,2,3,4). The blood test revealed white blood cell(WBC) 33.41*10^9/L, neutrophil(NEU) 30.84*10^9/L and procalcitonin(PCT) 1.34ng/ml. And the physical examination found positive sign of left knee abduction stress test, left hip abduction and external rotation test and straight leg raising test. All the above indicated us that the patient had a severe soft tissue infectious condition of left lower limb and retroperitoneal space.
(The red arrows in Fig. 1,2,3,4 respectively revealed the lesion tissue of pelvis, retroperitoneal space, hip joint and left lower limb.)
On admission we immediately started continuous ECG monitoring,
pulse oximetry, non-invasive blood pressure measurements and admission examination revealed the following: a weight of 70kg, a height of 173 cm, a temperature of 35.4°C, a heart rate of 108 beats/min, a respiratory rate of 17 breaths/min, a blood pressure of 94/69mmHg, and a SaO2 of 99%. The patient was in a listless state. Results of the laboratory examinations are shown in Table 1. At the same time, we treated the patient with Meropenem 1g IV every 8 hours and Linezolid 0.6g IV every12 hours according to the empirical antibiotic therapy, in combination with fluid replacement, analgesic treatment, Gastric mucosal protection, myocardiac nutrition and respiratory management.
Table 1
Results of Laboratory Examinations
Type of test
|
Patient’s value
|
Normal range
|
white blood cell count(WBC)
|
17.38*10^9/L
|
3.5–9.5*10^9/L
|
neutrophil ratio(NEU%)
|
91.5%
|
40–75%
|
level of C reactive protein(CRP)
|
191mg/L
|
< 8mg/L
|
procalcitonin(PCT)
|
5.41ng/ml
|
< 0.1ng/ml
|
erythrocyte sedimentation rate(ESR)
|
31mm/h
|
0-15mm/h
|
pH of arterial blood
|
7.52
|
7.35–7.45
|
lactic acid of arterial blood
|
1.8mmol/L
|
0.5-2.2mmol/L
|
HCO3− of arterial blood
|
20.4mmo/L
|
21-28mmol/L
|
glucose
|
9.5mmo/L
|
3.9-6.1mmo/L
|
alanine aminotransferase(ALT)
|
15U/L
|
< 35U/L
|
aspartate aminotransferase(AST)
|
12U/L
|
< 35U/L
|
albumin(ALB)
|
19.4g/L
|
35-55g/L
|
albumin/globulin (A/G)
|
0.7
|
1.2–2.4
|
total bilirubin(TBIL)
|
15.2mmol/L
|
5-21mmol/L
|
direct bilirubin(DBIL)
|
9mmol/L
|
< 6mmol/L
|
prothrombin time(PT)
|
17.7s
|
11-14.5s
|
activated partial thromboplastin time(APTT)
|
37.2
|
28-45s
|
fibrinogen degradation product(FDP)
|
6.42ug/L
|
2-4g/L
|
(1–3)-β-D Glucan, Fungus(G test)
|
negative
|
NA
|
serological test of aspergillus (GM test)
|
negative
|
NA
|
human Immunodeficiency Virus
|
negative
|
NA
|
blood culture(after 3 days)
|
negative
|
NA
|
sputum culture(after 3 days)
|
negative
|
NA
|
On the second day CT scan of head and chest showed bilateral lungs inflammation with mild pleural effusion and emphysema. In order to improve the patient’s immunity and prevent the infection from spreading, human serum albumin and immunoglobulin were added into treatment. Based on such data, after multidisciplinary consults, a debridement and exploration of pelvis, hip and left lower limb, followed by vacuum-assisted closure (VAC) therapy(KCI Inc., San Antonio, Texas, USA), was at last performed(Fig. 5,6,7,8). However, intraoperative microbiological sampling revealed nothing.
(Fig. 5, The marker line of left lower limb. Figure 6, The marker line of left lower abdomen. Figure 7, The abscess of left lower limb during the first surgery. Figure 8, The wound after debridement during the first surgery. )
In the following days, the patient’s condition improved and laboratory examinations showed the decline of inflammatory indicators in varying degrees. Therefore, after five days in ICU, the patient was transferred to the general ward in our Department of Burns and Plastic Surgery and meanwhile Meropenem regime was changed from every 8 hours to every 12 hours.
On the sixth day, a CT scan of chest,abdomen,pelvis and lower limbs was performed and still showed subcutaneous pneumatosis of left lower limb and retroperitoneal space. So the next day another debridement was carried out, followed by VAC and intraoperative microbiological sampling again. What should be mentioned is that a incident of temporary hypotension occurred during the surgery and was successfully relieved. However,Just two hours after the patient being delivered to the ward, the hypotension got back and worsen. BP 75/49mmHg, HR 120/min, SpO2 70%, with cold skin of the extremities, thick and coarse breath sounds and wet rales in bilateral lungs, restless and delirium state of the patient, five seconds the capillary refill time exceeding, we immediately realized that septic shock complicated with dysfunction of heart happened and almost at once we start fluid resuscitation, anti-shock therapy with Norepinephrine(0.05 mg/kg/min, 24h maintenance). Meanwile, the laboratory examinations were rechecked and the results were showed in Table 2. After two hours of treatment, the blood pressure of the patient gradually recovered and the heart rate decreased.
Table 2
Results of Laboratory Examinations
Type of test
|
Patient’s value
|
Normal range
|
white blood cell count(WBC)
|
37.83*10^9/L
|
3.5–9.5*10^9/L
|
neutrophil ratio(NEU%)
|
83.8%
|
40–75%
|
level of C reactive protein(CRP)
|
85.94mg/L
|
< 8mg/L
|
procalcitonin(PCT)
|
3.67ng/ml
|
< 0.1ng/ml
|
B-type natriuretic peptide(BNP)
|
1106pg/ml
|
NA
|
pH of arterial blood
|
7.49
|
7.35–7.45
|
lactic acid of arterial blood
|
5.5mmol/L
|
0.5-2.2mmol/L
|
HCO3− of arterial blood
|
16.8mmo/L
|
21-28mmol/L
|
glucose
|
5.7mmol/L
|
3.6-6.1mmol/L
|
alanine aminotransferase(ALT)
|
54U/L
|
< 35U/L
|
aspartate aminotransferase(AST)
|
45U/L
|
< 35U/L
|
albumin(ALB)
|
25g/L
|
35-55g/L
|
albumin/globulin (A/G)
|
0.73
|
1.2–2.4
|
total bilirubin(TBIL)
|
80mmol/L
|
3-22mmol/L
|
direct bilirubin(DBIL)
|
40mmol/L
|
0-5mmol/L
|
On the 12th day, intraoperative microbiological sampling yielded methicillin-resistant staphylococci(MRS) isolates and showed sensitive to vancomycin. Antibiotic therapy was therefore modifed. Meropenem and Linezolid were substituted with Vancomycin IV 1g every 12hours.
Regardless of the clinical improvement after three more surgical debridements of necrotic soft tissue and followed VAC, the patient persisted with a irregular fever(Fig. 9) and inflammation condition (Fig. 10) which the blood test had indicated. Multiple sampling during the surgery finally revealed the carbapenems-resistant Acinetobacter baumanii(CRAB) isolate which was only sensitive to Tigecycline, and Eikenella corrodens isolate. And then Tigecycline (IV 50mg every 12 hours)was added to antibiotic therapy.
In the following days, the patient got better gradually and the laboratory examinations showed a consequent improvement. Finally the skin suturing was carried out and the patient discharged from hospital on the 68th day after a full recovery. After suffering all these traumatic interventions, the patient felt grateful deeply and send his gratitude to us for saving his life.