CytoSorb in a case of fulminant toxic shock syndrome from ß-hemolytic streptococcus group A with severe circulatory shock and multiple organ failure

Dr. Markus Engel, Senior Consultant Medical ICU, Hospital Bogenhausen, Munich, Germany

Summary:

This case study reports on a 46-year-old female patient who was admitted to emergency department with beginning septic shock.

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Case presentation

  • 14 days prior in proctological treatment for rectal herpesvirus infection and initiation of therapy with acyclovir
  • Since 3 days painful swelling of lymph nodes in the groin and for the last 2 days chills followed by abdominal pain, diarrhea and vomiting
  • Suspecting toxic shock syndrome, the contraceptive coil was removed and patient was started on broad-spectrum antibiotic therapy
  • Venous blood gas analysis exhibited metabolic acidosis (pH 7,26, BE -9, 2mmol/l, lactate 8,22 mmol/l)
  • On admission to ICU patient was awake and fully oriented, however despite massive fluid replacement (+8000 ml until transfer) and noradrenaline administration persistent hypotension (70 mmHg systolic) and tachycardia
  • In the following hours development of fulminant shock syndrome with massive volume requirement, highest needs for catecholamines (noradrenaline up to 4.5 mg/h), respiratory insufficiency, oliguria/anuria, capillary leakage and pronounced disseminated intravascular coagulation (DIC)
  • Explorative laparotomy with unclear abdomen and further deterioration of clinical status gave no indication on the septic focus
  • Due to multiple organ failure (4) because of the massive inflammatory reaction as well as a persisting hitherto therapy-refractory septic shock, CRRT was started in combination with CytoSorb therapy

Treatment

  • One CytoSorb treatment sessions for a total period of 24 hours
  • CytoSorb was used in conjunction with CRRT (multiFiltrate, Fresenius Medical Care) in CVVHD mode
  • Blood flow rate: 100 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Lactate

Results

  • Hemodynamic stabilization of the patient with significantly decreased needs for catecholamines
  • Effective reduction of lactate levels during the CytoSorb sessions

Patient Follow-Up

  • Diagnosis of toxic shock syndrome with proof of ß-hemolytic streptococcus on removed coil
  • Despite hemodynamic stabilization severe microcirculatory failure with necrosis on hands and feet on both sides
  • In the further course short uroseptic period with urine congestion of unclear etiology (Double J placement)
  • Necessity for amputation of the right hand and lower legs on both sides
  • Finally successful transfer to rehabilitation unit

Conclusiones

  • Treatment with CytoSorb resulted in a significant stabilization of hemodynamics  and declining needs for catecholamines as well as an effective reduction of lactate plasma levels

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