SESSION TITLE: Critical Care Student/Resident Case Report Posters II
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Staphylococcus aureus enterocolitis has been increasingly reported in recent times with an interesting sinusoidal trend over the last many decades. Given the paucity of literature on its role in the pathogenesis of shock, we herein report such a case.
CASE PRESENTATION: Sixty-seven year old Caucasian female with hypertension and hyperlipidemia developed abdominal pain after eating at a local fast food restaurant. Over the next few hours, she developed worsening symptoms and became unresponsive. After extensive cardio-pulmonary resuscitation, the patient was transferred to our tertiary care center hypothermic, requiring mechanical ventilation and intravenous dobutamine. Her laboratory parameters showed WBC count 43,400/mm3, serum creatinine 2.5 mg/dL, AST 1853 IU/L and ALT 802 IU/L, lactate 11.2 mmol/L and arterial pH 7.05. The patient’s abdominal CT revealed free peritoneal fluid without evidence of perforation, and paucity of colonic gas suggestive of ileus. In addition to aggressive volume resuscitation empirical antimicrobial therapy was started (vancomycin, ciprofloxacin and metronidazole). Stools cultures were positive for Staphylococcus aureus on two different occasions. Rectal erosions on colonoscopy showed inflammatory pathology. Patient responded to aggressive resuscitation over the next several days. Her leukocytosis improved and liver enzymes normalized. She was discharged home in a stable condition.
DISCUSSION: In our patient, temporal relationship to her getting sick and eating at an outside facility, two sets of stool cultures growing Staphylococcal aureus and lack of another etiology for shock were important diagnostic clues. Increasing use of Metronidazole has been postulated as a cause for the re-emergence of Staphylococcal aureus enterocolitis. Mechanisms of shock are poorly understood; but bacteremia, toxin production and dehydration have been postulated. Varying mucosal appearances ranging from mild erythema (as in our case) to extensive necrosis have been reported. Although oral vancomycin is the preferred therapy, its utility in enterocolitis-induced shock has not been studied.
CONCLUSIONS: Staphylococcus aureus enteritis should be considered as an etiology for shock in the setting of food borne illness when no other pathogen can be identified. Early recognition and aggressive supportive care is the cornerstone of management for this rare condition.
Reference #1: Lin Z, Kotler DP, Schlievert PM, Sordillo EM. Staphylococcus Enterocolitis: Forgotten but not gone? Dig Dis Sci. 2010 May;55(5):1200-7.
Reference #2: Kolter DP, Sordillo PM. Review: A case of Staphylococcal aureus Enterocolitis: A rare entity. Gastroenterol Hepatol (N Y). 2010 Feb;6(2):117-9.
Reference #3: Kotler DP, Sandkovsky Y, Schlievert PM, Sordillo EM. Toxic Shock-like Syndrome associated with Staphylococcus Enterocolitis in an HIV-infected man. Clin Infect Dis. 2007 Jun 15;44(12):e121-3.
DISCLOSURE: The following authors have nothing to disclose: Saraschandra Vallabhajosyula, Pranjal Sharma, Pranathi Sundaragiri, Pallavi Bellamkonda, Savio Reddymasu, Lee Morrow
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