A 51-year-old male patient was admitted to the emergency room for 10 days with fever of 40oC, associated with diaphoresis and liquid stools without mucus or blood.
She had a history of cholecystectomy by laparoscopy 41 days before, which required hospitalization for 31 days for the treatment of a surgical site infection with organ/space involvement, treated with meropenem.
There was no invasive hemodynamic monitoring and no history of intravenous illicit drug use.
The physical examination revealed alertness, orientation, heart rate of 72 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 95/57 mm Hg, temperature of 38.5°C holist aortic focus II sealant.
Abdominal pain was present due to epigastric tenderness without signs of peritoneal irritation.
Laboratory tests showed preservation of renal function, normocytic, normochromic anemia, without leukocytosis or neutrophilia in the complete blood count, elevated C-reactive protein (CRP) and mild increase in alkaline phosphatase normal range and a.
In addition, an abdominal ultrasound showed intestinal loop distraction and stenosis.
Hepatitis B surface antigens and hepatitis C antibodies were negative.
On the sixth day of hospitalization, the patient remained febrile, with elevated acute phase reactants and signs of systemic inflammatory response; preliminarily, two hemocultives were reported showing growth of Gram negative bacilli.
At this time, antibiotic treatment was initiated with 4.5 g intravenous piperacillin/tazodone every six hours, under the diagnostic impression of cholangitis.
After the initiation of therapy, there was an improvement in liver function tests, but the value of the therapy increased and there was persistence of signs of systemic inflammatory response (tachyPCR and antibiotic fever) with thrombocytopenia.
A central venous catheter was placed for hemodynamic monitoring.
On the ninth day of hospitalization, on physical examination, hyperpigmented papules were found in palms and soles, right subconjunctival hemorrhage and a painful subcutaneous nodule in the left elbow.
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On the tenth day of hospitalization, blood cultures showed an increase of P. aeruginosa with intermediate sensitivity to imipenem (bad inhibitory concentration (MIC) of 8), sensitive to amikacin (MIC<8).
Antibiotic therapy was adjusted to meropenem plus amikacin.
Abdominal computed tomography showed enlarged spleen and circumscribed hypodense images.
On the twelfth day of hospitalization, the patient presented paresis of the left lower limb. A computed tomography scan of the brain showed bilateral occipital and parietal hypodense lesions.
At this time, a transesophageal echocardiogram showed a mobile vegetation of 5 mm in the aortic valve.
The patient continued with systemic inflammatory response and right transaminase and cerebral palsy on the 14th day, presented sudden deterioration of left hemiparesis and left hemiparesis with progressive hemorrhagic signs, focal abdominal CT scan, left hemiparesis and left ventricular tachycardia.
Orotracheal intubation was performed to protect the airway.
On the sixteenth day of hospitalization, the patient presented clinical deterioration due to oliguria, increased oxygen extraction and a significant decrease in hemoglobin levels.
Inotropic support with dobutamine was started.
He did not develop fever later and, the next day, neurological improvement without sedation, left hemiplegia and motor aphasia with Glasgow scale improved to 13/15, so he did not require steroid support.
Two blood cultures were received after the beginning of treatment with meropenem and amikacin, which reported P. aeruginosa growth in the first and no colony growth in the second.
On day 30 of hospitalization, the patient presented resolution of the aphasia, without complete recovery of the strength of the left hemibody and without new signs of systemic inflammatory response.
42 days of combined antibiotic treatment were completed.
