Abstract
Introduction: We still rely on clinical diagnosis for initiating empirical antibiotic therapy and await blood culture for confirmation of infection, species identification and drug sensitivity. Differential blood cell count (WBC and neutrophils) and recording of toxic granules in the neutrophils are established methods for indirect diagnosis of infection though they are not used in the diagnosis of sepsis per se. Serum Procalcitonin is considered as a good biomarker in the management of sepsis. Materials and Methods: Whole blood and serum were used for laboratory analysis. We have combined the detection of toxic granules in the peripheral blood smear and serum PCT levels for diagnosis and monitoring the recovery of a patient with septic shock. A 63 year old laminectomy patient was transferred 2 days after the surgery to our hospital with several co-morbidities and complications. He was in septic shock and was put on Continuous Renal Replacement Therapy, with ionotropic support and IV fluids via nasogastric feeding and administration of Activated Protein C. Blood culture and daily measurements of serum Procalcitonin, differential blood cells count, and observation of toxic granules in neutrophils were done. Results: The blood culture showed infection due to K. pneumoniae resistant to carbapenems. WBC and Neutrophil counts were quite variable and showed incoherent response to treatment. Serum PCT was 24.57 ng/mL on the next day of admission and it peaked at 30.2 ng/mL on day 3. Its level started decreasing from the 4th day. Toxic granules disappeared when serum PCT levels reached < 1 ng/mL. The patient responded well to treatment and he was discharged on the 16th day upon request. Conclusion: This case is presented as an example of managing sepsis with a combination of a conventional hematology marker and a modern biomarker. Resource poor hospitals with inadequate microbiology services, may evaluate and use these two biomarkers not only for the total management of sepsis but also to reduce the cost of critical care.
Highlights
We still rely on clinical diagnosis for initiating empirical antibiotic therapy and await blood culture for confirmation of infection, species identification and drug sensitivity
Differential blood cell count (WBC and neutrophils) and recording of toxic granules in the neutrophils are established methods for indirect diagnosis of infection though they are not used in the diagnosis of sepsis per se
Though serum PCT levels are not elevated in viral infections [15], it is significant that this study demonstrates that serum PCT responds strongly in a HIV positive patient who had secondary bacterial infection
Summary
Sepsis is the most common cause of death in noncoronary Intensive Care Units (ICU) with a reported mortality of 29% in the US and 27% in Europe [1], in elderly, immuno compromised/suppressed and critically ill patients. Trophils count and serum C-reactive protein (CRP), are non-specific and are often influenced by factors other than infection. Their status may not directly correlate to either progression or control of infection. Serum PCT based algorithm has been designed and used to guide the management of sepsis in many countries in Europe and the USA [7,8,9,10]. In India, quantitative serum PCT assay (LIA) has been evaluated in infectious pyelonephritis [11] in children, infective febrile conditions in intensive care units [12] and a semi-quantitative rapid test device was used in two other studies [13,14]. Though serum PCT levels are not elevated in viral infections [15], it is significant that this study demonstrates that serum PCT responds strongly in a HIV positive patient who had secondary bacterial infection
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