CytoSorb in Staph aureus sepsis and myositis-associated rhabdomyolysis

Katrin Przybilla and Andreas Bauer; Medical Clinic, Department of Intensive Care Medicine; Diakonissen Hospital Dresden, Germany

Summary:

This case study reports on a 61-year-old female patient who presented at the hospital with fever, vomitus and signs of sepsis a few days after completion of her 11th cycle of adjuvant chemotherapy with Paclitaxel due to mamma carcinoma.

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Case presentation

  • Rapid deterioration of her hemodynamic situation and kidney function
  • High plasma levels of inflammatory markers – leucocytes 24.000/µl, CRP 380 mg/l, PCT 45.1 ng/ml
  • Additional clinically pronounced myositis (muscle inflammation) with myoglobin plasma levels of 6049 µg/l
  • Erythema multiforme with proof of Staph aureus in wounds and suspicion of toxic shock syndrome
  • Development of acute anuric renal failure with immediate initiation of citrate dialysis (CVVHD)
  • Progressive deterioration of hemodynamic condition with high need for catecholamines (norepinephrine 4 mg/h)
  • In the further course fulminant septic shock with renal and circulatory failure as well as highly elevated markers of inflammation resulting in the installation of CytoSorb into the CRRT circuit

Treatment

  • One CytoSorb treatment session for 24 hours
  • CytoSorb was used in conjunction with citrate dialysis (Multifiltrate; Fresenius Medical Care) in CVVHD mode
  • Additionally, an EMic2 filter was installed for the treatment of highly elevated myoglobin plasma concentrations (CytoSorb in series before EMiC2 filter)
  • Blood flow rate: 150 ml/min
  • Anticoagulation: citrate
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Demand for catecholamines
  • Inflammatory parameters (leucocytes, CRP, PCT)
  • Myoglobin plasma concentration

Results

  • Hemodynamic stabilization with reduction of catecholamine dosages to 2 mg after termination of CytoSorb treatment and gradual weaning from catecholamines with complete stop 4 days after start of CytoSorb therapy
  • Leucocytes fell to 18000/µl four hours after start of CytoSorb treatment and continued to decrease to normal values in the further course
  • CRP plasma levels decreased to 260 mg/l four hours after start of CytoSorb treatment and to 85 mg/l in the further course
  • PCT could be reduced to 13.7 mg/l after 24 hours of CytoSorb treatment
  • Myoglobin plasma concentrations were reduced to 3168 µg/l and to 665 mg/l in the further course

Patient Follow-Up

  • Further improvement of all organ functions in the following days
  • Following intermittent termination attempts CRRT could be stopped 16 days after start of CytoSorb therapy
  • Patient could be discharged to rehabilitation with persistent critical illness myopathy and neuropathy 32 days after CytoSorb treatment

Conclusions

  • Combined treatment of CRRT with CytoSorb resulted in a clear and quick stabilization of hemodynamics with declining needs for catecholamines and a significant reduction of inflammatory mediators
  • The combined application of CytoSorb and the EMiC2 filter was also associated with a rapid reduction of myoglobin plasma levels as a result of myositis-associated rhabdomyolysis
  • For the treating physicians, this was the 2nd case with an excellent experience using CytoSorb in a patient with fulminant septic shock
  • Handling of the adsorber was easy and safe