MASKED SEPSIS DUE TO ACUTE CHOLECYSTITIS IN A PATIENT WITH CARDIOPULMONARY DISEASE LEADING TO SEPTIC SHOCK: 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: Sepsis is a primary cause of death in nearly 23.5% of chronic heart failure patients. The relationship between acute cholecystitis and cardiovascular disease is vague but there have been few studies suggesting cholecystocardiac link. Here we describe a similar case that presented as pulmonary edema and myocardial ischemia. CASE PRESENTATION: 81-year-old male with past medical history of myocardial infarction, chronic obstructive pulmonary disease, hypothyroidism, hypertension, hyperlipidemia presented to the emergency department with worsening exertional dyspnea for the past 3 days. On physical examination he was afebrile, tachycardic, hypoxic requiring 4L oxygen. Chest auscultation revealed bibasilar rales. Electrocardiogram showed ST segment depression in lateral leads and troponins were elevated at 1.56. Labs showed mild leukocytosis, BNP 1658, Creatinine 1.8 and normal hepatic panel. Chest X-Ray suggested pulmonary edema for which he was diuresed. He was started on heparin drip. Echocardiogram showed reduced ejection fraction of 40%. Cardiac catheterization showed multivessel disease and moderate pulmonary hypertension. Coronary artery bypass surgery was recommended. Next day he developed mild periumbilical pain, which later moved to his right upper quadrant. CT abdomen showed cholelithiasis with pericholecystic inflammation. Cholescintigraphy confirmed acute cholecystitis. Patient started becoming more dyspneic and pulmonary edema worsened. He became hypotensive and febrile. Sepsis bundle was initiated including blood cultures, broad spectrum antibiotics and intravenous fluids. Patient was intubated and transferred to critical care unit. He required multiple pressors. Continuous hemodialysis was started for metabolic acidosis. Blood cultures revealed gram negative bacteremia. Unfortunately, the patient could not be saved. DISCUSSION: Gallbladder edema may be a response to the ischemia caused by cardiac instability. The exact mechanism linking acute cholecystitis to extracholecystic diseases is unknown, but it is likely due to an increase in portal venous pressure along with a decrease in plasma oncotic pressure. Chronic cardiopulmonary diseases and aging can cause immune-senescence that may increase the risk of sepsis which sometimes does not meet SIRS criteria. These patients, especially when on betablockers, cannot meet increased metabolic demands. Irritation and spasticity of the gallbladder can create reflex stimuli through the autonomic pathways, which leads to temporary alteration in coronary blood flow. CONCLUSIONS: Acute cholecystitis may coexist with or be misdiagnosed as a cardiovascular disorder. Looking for signs of end organ dysfunction or subtle vital sign irregularities may help identify older patients who are on their way to decompensation and allow us to intervene earlier with appropriate investigations and treatment which may lead to the prevention of fatal events. Reference #1: Ozeki M, Takeda Y, Morita H, et al. Acute cholecystitis mimicking or accompanying cardiovascular disease among Japanese patients hospitalized in a Cardiology Department. BMC Res Notes. 2015;8:805. Published 2015 Dec 19. doi:10.1186/s13104-015-1790-8 Reference #2: Walker AMN, Drozd M, Hall M, et al. Prevalence and Predictors of Sepsis Death in Patients With Chronic Heart Failure and Reduced Left Ventricular Ejection Fraction. J Am Heart Assoc. 2018;7(20):e009684. doi:10.1161/JAHA.118.009684 Reference #3: Meelu OA, Baber U, Theodoropoulos K, Mennuni MG, Kini AS, Sharma SK. Acute cholecystitis and myocardial infarction: a case study with coronary involvement. Clin Case Rep. 2016;4(8):793-796. Published 2016 Jul 13. doi:10.1002/ccr3.621 DISCLOSURES: No relevant relationships by Aditya Bansal, source=Web Response No relevant relationships by Hina Farrukh, source=Web Response No relevant relationships by sreeja sompalli, source=Web Response