A 62-year-old man presented to the Emergency Department complaining of sudden onset epigastric pain of 3 hours duration in the context of vomiting, diarrhea without previous episodes of colitis.
As the only pathological antecedent, the patient was seropositive for HIV infection, followed antiretroviral treatment and the last CD4 determination was 350-450 cells/ml with undetectable viral load.
Upon arrival at the Emergency Room, the patient had a poor general condition, mucocutaneous dryness and professional mental retardation.
Vital signs were stable (blood pressure 100/60 mm Hg and heart rate 85 bpm) and a 37.4 oC febricula was observed.
The abdomen was blandom and tender for fixation in the epigastrium, with signs of peritoneal irritation at that level.
Blood tests revealed acute renal failure (creatinine 4.1 mg/ dl), leukocytosis with young forms at the count (white blood cells 6.20 x 109/ l, neutrophils 71 % and reactive protein 2.4 mg mmol/ l)
The ECG, abdominal and thoracic radiographs showed no abnormalities.
During his stay in the emergency room, the patient rapidly progressed to hemodynamic instability and developed septic shock. Resucital measures and empirical antibiotic therapy with cefoxime and metronidazole were initiated.
Abdominal CT showed diffuse thickening of the gastric walls and antral region, with changes in density of fat planes adjacent to the greater curvature pneumoperitoneum and absence of free fluid.
These findings were requested fibrogastroscopy which showed increased gastric size, edematous and erythematous, findings compatible with phlegmonous gastritis and a C fold of Los Angels.
Given the initial hemodynamic instability and acute renal failure with oliguria, the patient was admitted to the Intensive Care Unit, requiring vasoactive drugs during the first 24 hours invasive mechanical ventilation support, enteral insufficiency and renal failure.
Anatomopathological analysis of gastric biopsies reported acute inflammation with submucosal dissection, confirming the diagnosis of phlegmonous gastritis.
The cultures of the biopsies and the blood culture were positive for Streptococcus pyogenes, so the antibiotic treatment was modified to penicillin G and clindamycin, according to the antibiogram.
As a complication secondary to resuscitation measures, the patient developed acute pulmonary edema and pneumonia.
The subsequent evolution was favorable and the patient was discharged 28 days after admission, without presenting new abdominal symptoms.
