29/2016
CytoSorb in acute purulent abscess inflammation of the epididymis

Dr. Harald Penz, Department for Anaesthesiology and Intensive Care Medicine, Landesklinikum Gmünd-Waidhofen/Thaya-Zwettl, Location Waidhofen/Thaya, Austria

Summary:

This case study reports on a 69-year-old male patient who fell on his right leg and hip, lying on the lower leg for about 4 hours with his entire weight, who was then salvaged by helpers and brought to the orthopedic department for further examination.

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Case presentation

  • Previously existing inflammatory problem of the epididymis for several days which was treated on an ambulatory basis
  • X-ray examination showed no deterioration of any bone structures
  • However, at this time the patient already exhibited elevated levels of creatinine (2.7 mg/dl), CRP (27 mg/dl) and leukocytes (32,000 /µl) as well as highly elevated liver function parameters
  • The next day there was a further increase of CRP to 40 mg/dl, PCT to 17.3 ng/ml and CK to 24,000 U/l (CK-MB was only minimally increased)
  • Primary suspicion for urosepsis followed by an immediate transfer to the urology department and subsequent operation with orchiectomy (septic testicles)
  • Postoperative transfer to ICU and further increase of creatinine (to 8.2 mg/dl within 3 days), urea of 106 mg/dl, glomerular filtration rate of 7 ml/min, despite massive hydration
  • Initiation of antibiotic therapy with ceftriaxone
  • Immediately after admission to ICU and due to acute renal failure, a strong increase in plasma levels of inflammatory mediators and increasing needs for catecholamines, CytoSorb therapy was started

Treatment

  • Six consecutive CytoSorb sessions for a total treatment time of 122 hours, the first two treatments were run for 12 hours, the additional 4 treatments for 24 hours each
  • CytoSorb was used in conjunction with citrate dialysis (Prismaflex; Gambro) performed in CVVHD mode
  • Blood flow rate initially 100 ml/min, then increase to 130 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: post-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (CRP, PCT)
  • Renal function (creatinine, glomerular filtration rate)
  • Creatine kinase (CK) and myoglobin

Results

  • Within the following 4 days of CytoSorb treatment hemodynamics could be stabilized within just a few hours and catecholamines (norepinephrine) could be tapered out from an initial dose between 0.023-0.035 µg/kg/min in the following days
  • In these 4 days CRP decreased from initially 40 mg/dl to 6.7 mg/dl, PCT could be reduced from 17.3 ng/dl to 0.64 ng/dl, leucocyte count decreased from 40,000/µl to 11,600/µl
  • Myoglobin levels were reduced from 311 ng/ml to 104 ng/ml in the same time frame
  • Likewise, CK- values were lowered from initially 24,000 U/l to 853 U/l and in the further course to 389 U/l

Patient Follow-Up

  • Eventual diagnosis of the pathologist: Acute purulent abscess inflammation of the epididymis spreading out to the testicles and the tissue of the spermatic cord
  • 13 days after the last CytoSorb treatment the patient was transferred to the normal ward for further therapy in good general condition with further declining CRP (4.6 mg/dl), leukocytes and thrombocytes in the normal range, however still with increased renal retention parameters (creatinine 3.3 mg/dl)
  • The clinical course of the beginning compartment syndrome of his right leg was also positive
  • The right calf appeared much softer, no more pressure sensitivity, mobility intact
  • Gross neurology was recurring and appropriately at the time of documentation, sensitivity present

Conclusions

  • Significant stabilization and consolidation of hemodynamic and inflammatory parameters during and after CytoSorb therapy
  • The application of CytoSorb therapy was easy and safe, with no application-specific complications emerging