On day 24, the patient underwent a total colectomy, cholecystectomy, and ileostomy for acalculus cholecystitis and for removal of a potential abdominal source of sepsis. The exploratory laparotomy with cholangiogram showed ascites, a cirrhotic liver, an inflamed distended gallbladder, and no evidence of cholangitis. On day 25, the patient developed severe metabolic acidosis with worsening renal function requiring continuous venovenous hemofiltration. His condition deteriorated rapidly with worsening ARDS and multisystem organ failure, despite maximal life-sustaining therapy. At that time, LFTs revealed an AST level of 1,408 U/L and an ALT level of 2,195 U/L. Arterial blood gas levels when the patient had a 100% fraction of inspired oxygen were as follows: Pco2, 57 mm Hg; Po2, 47 mm Hg; and pH 7.17. On day 26, blood culture results came back positive for methicillin-resistant Staphylococcus aureus and Candida albicans. Sputum culture results also were positive for methicillin-resistant S aureus. The patient died on day 26, and an autopsy was performed.