Non-zoonotic Pasteurella multocida Infection as a Cause of Septic Shock in a Patient with Liver Cirrhosis: A Case Report and Review of the Literature
A 52-year-old African American female was brought to the emergency department for generalized abdominal discomfort, altered mental status, diarrhea, fevers and chills for 4-5 days. Her past medical history was significant for alcohol abuse and alcohol-related liver cirrhosis. In the emergency department, vital signs were as follows: Blood pressure of 74/42 mmHg, heart rate of 112 beats/min, respiratory rate of 20 breaths/min and temperature of 98.6 F. Remarkable findings on physical examination included jaundice as well as abdominal distention and tenderness to palpation, especially in the right upper quadrant. There was no rash or ulcers. As per family, she did not have recent travels or exposure to sick people. They denied having domestic animals at home or any contact to the patient with pets. She was placed on mechanical ventilation and admitted to the medical intensive care unit. Admission diagnosis was systemic inflammatory response syndrome with sepsis and septic shock with multi-organic dysfunction syndrome, presumptively secondary to community-acquired pneumonia, possible biliary tract infection (ascending cholangitis), probable spontaneous bacterial peritonitis (SBP) and alcoholic hepatitis. Aggressive intravenous fluids resuscitation with crystalloids along with vasopressors was initiated. Blood, urine, respiratory cultures and Legionella urine antigen were obtained. Empiric intravenous antimicrobial therapy, composed by piperacillin/tazobactam (2.25 g every 8 h) and azithromycin (500 mg every 24 h), was initiated.\nLaboratory results on admission were: A complete blood cell count of 21,000/mm3(90% neutrophils), a platelet count of 51,000/mm3, a sodium level of 127 mEq/L, a potassium level of 5.3 mEq/L, a bicarbonate level of 15 mEq/L and a creatinine level of 6.3 mg/dl. Aspartate aminotransferase and alanine aminotransferase levels were 121 and 65 IU/L, respectively. Alkaline phosphatase level was 290 IU/L, gamma-glutamyl transpeptidase level was 290 U/L and lactate dehydrogenase level was 482 U/L. Total bilirubin level was 14.5 mg/dl, with a direct bilirubin level of 10.1 mg/dl. Lactic acid level was 6.4 mg/dl. Prothrombine time was 25.2 s, with an INR of 2.29. Serum alcohol level was within the normal limits. Arterial blood gases showed a pH of 7.15, a pCO2 of 23, and a pO2 of 132 while the patient was receiving mechanical ventilation with FIO2 of 60%. Chest X-ray showed left lung infiltrate with pleural effusion.\nAfter 24 h of admission, patient remained in critical condition and requiring maximum doses of vasopressors, despite of what it seems to be the appropriate empiric antimicrobial therapy. Blood cultures drawn of admission grew P. multocida. Blood culture system Bact-Alert 3D® was used for the recovery of the organism. No polymerase chain reaction analysis was performed. Isolate was tested sensitive to piperacillin/tazobactam and azithromycin. No minimal inhibitory concentrations for these antimicrobials were reported. In spite of all medical efforts, general medical condition deteriorated and patient expired on day 3 of admission.