Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy

Hetz H, Berger R, Recknagel P, Steltzer H
AUVA Meidling Emergency Hospital, Department of Anesthesiology and Intensive Care Medicine, Vienna, Austria

Summary:

This case study reports on a 60-year-old female with no pre-existing diseases except hypertension and hypothyroidism presented at the hospital with radius fracture of the right forearm after an accident.

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Case presentation

  • Immediate wound care was achieved by application of a plaster splint followed by operative osteosynthesis on the same day
  • Swelling of the forearm expanding to the upper arm
  • Patient collapsed and was transferred to ICU with diagnosis of septic shock
  • Antibiosis and volume therapy were initiated while requirement for vasopressors drastically increased
  • Development of oliguric acute renal failure and ARDS and commencement of mechanical ventilation
  • Implementation of continuous veno-venous hemofiltration in combination with CytoSorb
  • In the further course proof of infection with β-hemolytic streptococci

Treatment

  • Three CytoSorb hemoperfusion sessions on the first day as well as on day 3 and 4 after ICU admission in combination with standard CVVHD
  • Treatment time was 36 hours in the first and 17-18 hours in the two following procedures
  • Blood flow rates 100 ml/min
  • Regional citrate anticoagulation

Measurements

  • Markers of inflammation, organ dysfunction and need for vasopressors
  • Leucocytes, platelets, IL-6, cumulative urine output, creatinine

Results

  • CytoSorb effectively and significantly reduced IL-6 levels
  • After the first session, IL-6 plasma concentration decreased from 70000 to 39100 pg/ml (-44.3%). The final IL-6 level after the third session was 66 pg/ml
  • CytoSorb treatment was paralleled by a significant decrease of vasopressor need
  • Antibiotic therapy was conducted with Ampicillin and Fosfomycin, with no reported adaption of dosage during CytoSorb therapy
  • The patient could be successfully stabilized until surgical control of the infectious source was achieved

Patient Follow-Up

  • After the third CytoSorb treatment hemofiltration was continued without CytoSorb as the need for vasopressors was significantly decreased and IL-6 levels were back in a normal range
  • Despite considerable reduction of IL-6 levels, amputation was inevitable
  • The general condition improved and the patient could be extubated 4 days after the third CytoSorb treatment

Conclusions

  • Treatment was safe and well-tolerated, without adverse events
  • CytoSorb significantly reduced IL-6, a predictor of mortality in sepsis and surrogate for cytokine storm
  • The patient could be successfully stabilized until surgical infectious source control was performed
  • CytoSorb in combination with CVVHD and regional citrate anticoagulation could be run continuously for up to 36 h
  • Hemoadsorption using CytoSorb seems to represent a promising approach for an effective and safe treatment of severe sepsis and septic shock.