Non-O1, non-O139 Vibrio cholerae sepsis in a patient with nephrotic syndrome
A 33-year-old lady presented with a history of recurrent episodes of headache, myalgia, and occasional episodes of nausea and vomiting for 5 months duration. She was evaluated elsewhere and was treated for migraine, without relief. She had intermittent episodes of hypotension with persistent leucocytosis, for which she was treated with multiple courses of empirical broad-spectrum antibiotics. She developed anasarca 1 month prior to visiting our centre. There was no history of hematuria or reduction in urine output.\nOn examination, she was afebrile; blood pressure (BP) was 110/70 mmHg without postural hypotension. Systemic examination was unremarkable. Investigations revealed nephrotic range proteinuria (14.3 g/day), microscopic hematuria (10-12 red blood corpuscle/high power field), hypoalbuminemia (0.8 g/dl), hypercholesterolemia (455 mg/dl), hypertriglyceridemia (352 mg/dl), and a serum creatinine of 1.08 mg/dl. She also had leucocytosis (15,500 cells/mm3) with a differential count of neutrophil 71%, lymphocyte 19%, eosinophil 3%, monocyte 6%, and basophil 1%. Anti-nuclear antibody (ANA) and anti-double stranded deoxyribonucleic acid antibody (anti-dsDNA) were negative; Complement C3c and C4 levels were normal.\nShe was started on diuretics and intravenous albumin for edema. Blood culture, performed in view of leucocytosis at admission, did not grow any pathogen. Renal biopsy revealed six glomeruli displaying mild increase in mesangial matrix with hypercellularity []. Immunofluorescence study was negative. A diagnosis of idiopathic unsampled focal and segmental glomerulosclerosis was made and she was started on prednisolone at a dose of 120 mg every alternate day. Subsequently, electron microscopy revealed mesangial proliferative glomerulonephritis with few small mesangial electron dense deposits. She was discharged to follow-up as an out-patient.\nFive days after starting oral steroids, she presented to the emergency department with myalgia, giddiness, and weakness. There was no history of fever. On examination, she had tachycardia, tachypnea, and hypotension. Systemic examination was unremarkable. Investigations revealed worsening leucocytosis (15,900 cells/mm3) with neutrophilic predominance (89%) and markedly elevated serum procalcitonin levels (144.5 ng/ml), suggesting possible bacterial sepsis with septic shock. After drawing blood for culture, she was started on broad-spectrum antibiotic coverage with intravenous meropenem. The total leucocyte count increased to 53,500 cells/mm3 the next day. Imaging of chest and abdomen did not reveal any focus of sepsis. The patient was managed in the intensive care unit with meropenem and inotropic support. Clinical improvement started after 72 hours of antibiotics with reduction of inotropic requirement and normalization of the total leucocyte count by the fourth day. Her blood culture grew non-O1, non-O139 V. cholerae, which was sensitive to ampicillin, tetracycline, cotrimoxazole, cefotaxime, ofloxacin, and meropenem. In view of V. cholerae sepsis, a stool culture was done, which did not grow any pathogen.\nOn further questioning, she recalled that 16 weeks before the onset of nephrotic syndrome, she had visited a beach for swimming and bathing. She did not consume any sea-food. The patient completed 2 weeks of meropenem, following which a repeat blood culture was documented to be sterile. She was then discharged in stable condition with advice to continue prednisolone for nephrotic syndrome.