INNOVATIVE USE OF HYDROXOCOBALAMIN WITH THIAMINE, ASCORBIC ACID, AND HYDROCORTISONE IN THE TREATMENT OF A SEPTIC SHOCK PATIENT WITH FULMINANT LEPTOSPIROSIS: A CASE REPORT

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Leptospirosis can escalate to septic shock and multi-organ failure. Despite consistent compliance to sepsis bundle, mortality rate remains high. In 2016, a retrospective study suggested the addition of thiamine, ascorbic acid and hydrocortisone to standard sepsis therapy can improve organ injury, shock time reversal, and mortality rate (1). Adjunctive high dose hydroxocobalamin has also been recently reported to reverse septic shock (2). We are reporting the first innovative use of hydroxocobalamin, thiamine, ascorbic acid, and hydrocortisone to standard sepsis protocol in rapid and successful reversal of septic shock in a case of fulminant leptospirosis. CASE PRESENTATION: A 59-year-old Pacific Islander presented with two days of recurrent headache, vomiting, abdominal pain, and myalgia. He was discharged after receiving antiemetics and fluids. Patient returned two days later with worsening abdominal discomfort, persistent headaches, coughing, and black tarry stool. He was admitted with acute respiratory distress syndrome, septic shock, acute liver and renal failure. Patient was placed on mechanical ventilation; he developed cardiac arrest for a brief period but had return of spontaneous circulation. Initial Sequential Organ Failure Assessment score was 16. With his history of working barefooted in a taro farm, it prompted an order for Leptospira Immunoglobulin M antibody test, which was positive. Along with intravenous fluid and broad-spectrum antibiotics, he required continuous norepinephrine, phenylephrine, vasopressin drips, and hydrocortisone. On day 3, hydroxocobalamin, thiamine, and ascorbic acid were added as adjunctive therapies due to continued hemodynamic compromise. Within 24 hours, he was successfully liberated off all vasopressors. Despite being in the intensive care unit for 16 days and a prolonged hospitalization, he was discharged home and continued to be functional and ambulatory one year later. DISCUSSION: Even with aggressive adherence to sepsis bundle in septic shock, mortality remains high. Despite numerous clinical trials, they have been unsuccessful in reversing this trend. Addition of thiamine, ascorbic acid, and hydrocortisone to multiple vasopressors have been reported to potentially address the hemodynamic derangement. More recently, there has been suggestion that hydroxocobalamin could further contribute to reversing these processes. CONCLUSIONS: This is the first known successfully rapid reversal of septic shock due to fulminant leptospirosis treated with combination of hydroxocobalamin, thiamine, ascorbic acid, and hydrocortisone, added to standard sepsis protocol. The combination of these vitamins and hydrocortisone resulted in synergistic and lasting effect of hemodynamic parameters that can potentially improve quality of health for septic shock survivors. Well-designed prospective studies are warranted to further evaluate their true efficacy. Reference #1: Marik, P. E., Khangoora, V., Rivera, R., Hooper, M. H., & Catravas, J. (2017). Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest, 151(6): 1229-1238. Reference #2: Lin, Y., & Vu, T. Q. (2019). Use of High-Dose Hydroxocobalamin for Septic Shock: A Case Report. A&A Practice, 12(9): 332-335. DISCLOSURES: No relevant relationships by Angelica Guzman Paz, source=Web Response No relevant relationships by Takkin Lo, source=Web Response