LAUSR

Learning Objectives: This is an unusual case of profound septic shock which occurred in the context of Ehrlichia infection. Methods: A 57-year-old male with hepatitis C and ongoing alcohol abuse presented with malaise, lightheadedness, bloody diarrhea, and altered mental status. His symptoms developed over 6-7 days after recent increased alcohol intake. He presented to an outside hospital, and on transfer was found to have acute kidney injury, elevated transaminases, hyponatremia to 123 mmol/L, profound hypoxemia, and bloody diarrhea with a coagulation defect. Initial thromboelastography revealed elevated R and K values. The patient was anemic and thrombocytopenic (21) with low fibrinogen (123mg/dl), although no schistocytes were observed on peripheral smear. His creatine kinase was also elevated to 9936 U/L. Multisystem organ failure progressed. He required mechanical ventilation and paralysis for acute respiratory failure and severe ARDS, three vasopressors for vasodilatory shock, and renal replacement therapy for acute kidney injury. The patient was initially treated with vancomycin and piperacillin-tazobactam, and shortly his blood cultures returned positive for E. coli. He also received hydrocortisone, thiamine, and vitamin C given his profound vasodilatory shock. Additional history provided by family described an engorged tic found on the patient’s scrotum one week prior to admission. With this new information, a superimposed Ehrlichia infection was detected via PCR serology, and doxycycline was added to his regimen on hospital day two. Over the next two days, his pressor requirement abated. The patient eventually improved in terms of his shock, but was never liberated from the ventilator or dialysis, and was transferred to an LTAC. Results: The immunocompromised patient was interestingly compromised by an Ehrlichia chaffeensis infection and developed impressive inflammation with DIC and profound shock. He received not only the doxycycline, but also the Marik protocol was used, supporting its role in these cases. Ehrlichiosis has a broad range of presentations including septic or toxic shock-like disease, respiratory failure, renal failure, coagulopathy. It is also common to see hyponatremia and elevated creatine kinase. The patient’s bloody diarrhea could also be from EHEC or from HUS, though no schistocytes were detected. Ehrlichiosis accounts for this patient’s dramatic presentation, which was more inflammatory than expected for E. coli infection alone.