A 56-year-old woman, housewife, presented with a three-day history of vomiting, melena, bilateral epistaxis, and two spontaneous hematomas (in the right hypochondrium).
He also reported asthenia and adynamia.
She had a history of hypertension and hypothyroidism under pharmacological management.
He had denied the recent use of alcohol, tobacco or psychoactive substances.
He was admitted to the local hospital in regular general condition, with blood pressure 62/45 mmHg, heart rate 130 per min, respiratory rate 23 per min, with oxygen saturation of 90% and body temperature of 37.5°.
Cardiopulmonary and abdominal examination was normal.
With an initial diagnosis of hypovolemic shock secondary to upper gastrointestinal bleeding, intravenous crystalloids were started.
Blood count showed pancytopenia (3.5mm3 hematocrit), predominantly neutrophils 2.937/mm3, platelets 97.000/mm3, 34% hemoglobin 7 g/dl).
Since she did not respond to crystalloid management, transfusion of blood products and inotropic support with vasoactive drugs were indicated.
Subsequently, the patient was referred to a higher complexity institution with an intensive care unit (ICU).
The patient was admitted to the institution with stable hemodynamics, blood pressure 100/75 mmHg, HR 112 per min, RR 22 per min, and oxygen saturation 93%.
On physical examination at admission the abdomen showed mucocutaneous noise, capillary filling less than 2 sec, moderate epistaxis, rhythmic heart sounds, good aggregated lung bases, very poor lung bases.
A post-transfusion blood count showed leukocytes of 2,903/μL, predominantly neutrophilic, platelets of 14,000/μL, normal hematocrit of 30% and hemoglobin of 6 g/dl. The direct coagulation time, transaminase
An abdominal computerized axial tomography (CAT) showed mild stenosis (low spleen 14.5 cm).
The diagnosis of acute idiopathic thrombocytopenic purpura (ITP) with anemia secondary to hemorrhage was proposed, so dexamethasone 40 mg IV daily for four days was indicated
The subsequent immunological study (complement C3, C4, total complement, rheumatoid factor, and plasma concentration of immunoglobulins A, G and M) were normal and the antinuclear antibodies (ANAs), anticardiolipin antibodies were negative.
Serology was requested for HIV, hepatitis B, C and VDRL, which resulted in no recurrence.
Blood PCR for cytomegalovirus was negative; no serology for Epstein-Pugh virus was requested.
Four days after the start of corticosteroids, during which the left pulmonary patient had a stable cough, presented signs of chest pain, with oxygen desaturation up to 75%, intercostal retraction and tortico-abdominal breathing associated with increased cough.
Blood count showed leukocytosis of 35,250/μL and neutrophilia (81%), with red blood cell recovery, platelets and coagulation tests.
CRP was 11.2 mg/dL (normal value < 0.5 mg/dL).
Both the chest X-ray and the CT scan showed a septate left pleural effusion without pulmonary infiltrate or consolidation.
Empirical antimicrobial management was initiated, such as a pleuropneumonia with piperacillin/tazo challenge 4.5 g iv every six hours, after taking two blood cultures by puncture.
Left sequestration resulted in 350 cc of purulent fetid material cultured in hemocultive vials.
Gram stain of both hemocultives and pleural fluid showed gram-negative bacilli.
Small round grey-colored colonies grew in chocolate agar in an aerobic environment after 24 h of inoculation, catalase and oxidase positive.
It was identified as P. canis by VITEK 2 Systems grading system: 03.01, with 100% certainty for the three samples.
No antimicrobial susceptibility study of the strain was available.
The patient was transferred to the ICU because he remained stable between 75 and 80% with a Venturi mask 50%, where he was intubulated, connected to mechanical ventilation and a pleural tube was placed.
Given the microbiological result, both in hemocul-tives and pleural fluid, and the hemorrhagic manifestations upon admission, the diagnosis of hemorrhagic septicemia and pleural empyema secondary to P. canis was considered.
The antimicrobial agent was administered for 14 days with satisfactory clinical evolution due to stabilization of vital signs and hemodynamics, as well as the possibility of extubation.
The patient and family were re-interrupted and denied recent contact with animals.
Unfortunately, the patient could not be followed up after discharge.
