A 19-year-old female patient was admitted to the intensive care unit.
Its clinical picture is characterized by general deterioration, generalized anxiety disorder, choluria, acholia and hyperthermia of 40oC; all these data are present for 5 days prior to admission.
The patient had a history of multiple foci of ecchymosis in the previous 3 months, use of oral contraceptives one month before admission, upper respiratory tract infection one month ago, exposure to social paintings and hypertension two weeks ago,
Treatment is carried out in the intensive care unit (ICU) for 12 days; the evolution is unfavorable and culminates in death, with the following relevant characteristics:
Upon admission, the patient is oriented in time, space and person, with signs of mucocutaneous fistulation moderate and generalized pruritus, hypotension and tissue hypoperfusion.
Without data on heart failure, a complete blood count revealed leukocytosis (1,300 leukocytes/μl) and thrombocytopenia,600 platelets/dl).
With these data, it is evaluated as liver failure under study and hypovolemic/septic shock, so treatment is initiated according to the objectives of Surviving Sepsis Campaign, 2008.
A total of 1,546 acute renal failure gastroenterological services evaluated the patient, which initially ruled out an infectious condition, highlighting severe hepatic insufficiency (total bilirubin of 13.8mg/dl, 3.0mg/dl ASTB of 12.1mg/dl).
The ICU classifies the clinical picture as APACHE II, with 27 points (mortality of 70.5%).
The condition is characterized by pericatheter hemorrhage and mucous membranes and coagulopathy data to which bradylalia is added; however, there are no data on intracraneal or focal hypertension
Serological studies are carried out, where anti-CMV antibodies of immunoglobulin type (Ig) G are found.
A new intravascular coagulation assessment performed 68μdl showed medullary failure (medullary biopsy revealed histiocytosis); in addition, erythrocytes were 3.415×106/μl, disseminated Hb was 9.8g/dl.
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Data on ventilatory distress are presented, so non-invasive mechanical ventilation is initiated and studies are complemented with ultrasound and abdominal computed tomography, which show hepatomegaly.
Respiratory distress increases, so invasive mechanical ventilation is initiated.
Despite treatment during hospitalization, there is a significant decrease in urinary volume and hemoglobin (7.4g/dl), so transfusion of erythrocyte concentrates is initiated.
Moreover, due to the greater ventilatory impairment, maneuvers for alveolar recapping are initiated.
After 5 days of hospitalization, the patient presented with gastrointestinal bleeding despite the use of proton pump inhibition.
Due to the complications and course of the disease, corticoid pulse and Ig administration were initiated.
The antibacterial coverage is corrected according to the hepatic insufficiency and the pharmacological treatment is implemented antifungals.
Despite this, after the above modification, the patient has a generalized skin rash, so the medication is regulated.
In the following days, the patient continues with disseminated intravascular coagulation data and is therefore continued with blood products.
Paraclinical tests of these days highlight mixed acidosis in gas.
Endoscopy showed persistent gastrointestinal bleeding, but there was no systemic repercussion.
A reduction in urinary volume is added to this process and the elevation of nitrogenous elements is included.
During the last 3 days of evolution, the patient continues with data of tissue hypoperfusion and greater decrease in urinary volume.
In addition, hyperkalemia (6.8mEq/l) is determined and its treatment is performed; in parallel hypotension occurs.
The clinical picture culminates when the patient presents ventricular tachycardia with idioventricular rhythm, which starts to asystole; despite advanced cerebral-cardiovascular resuscitation maneuvers, there is no favorable response and concludes in death.
