Streptococcus pneumonia is the most common cause of community-acquired pneumonia. Local complications include pleural effusion, empyema and pericarditis. Endocarditis, septic arthritis and meningitis can occur secondary to bacteremia. In sever cases disseminated intravascular coagulation can happen with bleeding and thrombosis. Systemic peripheral gangrene (purpura fulminans) has been described as a rare complication.
23 years old white male presented to the emergency room with productive cough, nausea, vomiting, abdominal pain and abdominal distention. He has past medical history of acute lymphoblastic leukemia at age five treated with chemotherapy and radiation and he has been in remission since that time. He had inguinal hernia repair as a child. He was not taking any medication. He did not drink, smoke or use illicit drugs. On physical exam he was drowsy, His blood pressure 124/60 mmHg, pulse 130 beat per minute, respiratory rate was 26 breaths per minute and his pulse oximetry was 100% on room air. He had bilateral basal crackles on his lung exam. His abdomen exam was consistent with acute abdomen (distended, rigid, rebound tenderness). He had trace lower extremity edema. His labs were white cell count 2800/cmm with 85% neutrophills, hemoglobin 12.9 g/dL, platelets 37,000/cmm, sodium 137 mEq/L, potassium 4.3 mEq/L, chloride 104 mEql/L, bicarbonate 16 mEql/L, blood urea nitrogen 30 mg/dL, Creatinine 1.4 mg/dL, glucose 47 mg/dL, INR 1.9, PTT 29.3 second, PT 22.1 seconds and lactate 8.7 mmol/L. His arteril blood gas was PH 7.22, PCO2 26.9 mmHg and PO2 70.8 mmHg on room air. He was found to be hepatitis C positive. His chest x-Ray showed Left lower lobe infiltrate with small effusion. CT scan showed pneumonic consolidation of the left lower lobe, cirrhosis of the liver, splenomegaly, thickening of the ascending, descending colon walls and terminal ileum. He was given Intravenous fluids, wide spectrum antibiotics (to cover for community acquired pneumonia and gut ischemia), bicarbonate drip for his metabolic acidosis. Surgical consult was obtained. He was taken to the operating room where he underwent right hemicolectomy secondary to ischemia and necrosis. His blood cultures came back positive for streptococcus pneumonia on his second hospital day. He went to the operating room multiple times for anasomosis of the bowels and stepwise closure of his abdomen. He was extubated on his sixteenths hospital day. He did well for two weeks before he was intubated and placed on mechanical ventilation. Patient condition continued to deteriorate after that secondary to liver failure, kidney failure and vancomycin resistant enterococcus sepsis.He died after long hospital stay. The pathology form the right colon came back as tansmural acute inflammation and hemorrhagic necrosis with associated acute inflammation of vessels wall, thrombosis and numerous diplococci.
In this case the patient was not hypotensive or on inotropic agent that may contribute to bowel ischemia. This leavs pneumococcal pneumonia bacteremia with invasion and thrombosis of blood vessels the cause of bowel ischemia.
There have been few reports about symmetrical peripheral gangrene (purpura fulminans) as a complication of pneumococcal sepsis. I would like to add bowel ischemia as an unusual complication of pneumococcal pneumonia. Physicians shuold keep in mind that in cases of sever pneumococcal sepsis blood vessels invasion by pneumococcua and thrombosis of these vessels can lead to serious ischemic complications.
K.R. Al Khasawneh, None.