UNUSUAL PATH FOR DISCOVERY OF SEPSIS ETIOLOGY

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by dysregulated host response to infection. The most challenging patients are the ones who have no clear source of infection. Current guidelines recommend empiric coverage for aerobic gram-positive and aerobic enteric gram-negative bacteria. When broad spectrum antibiotics fail, review of antibacterial spectra of activity and assistance of differential diagnosis generators may pave the path for culprit discovery. We present a case where the differential diagnosis generator helped us accurately diagnose and guide the appropriate therapy. CASE PRESENTATION: A female of 70-years with a history of osteoarthritis presented with four weeks of fever, weight loss, night sweats, and fatigue. She was hypotensive, febrile, tachycardic and tachypneic. Sepsis protocol was activated. Laboratory data revealed WBC 2.7 K/UL, Hgb 9.8 g/dL, PLT 77 K/DL, AST 71 IU/L ALT 49 IU/L, CRP 12 mg/dL, ESR 41 mm/hr. Ferritin 7138 ng/mL, LDH 570 IU/L. She failed to improve for the first 48 hours despite IV Vancomycin and Cefepime. A contrast-enhanced CT scan of the abdomen revealed splenic hypodensities; laboratory workup for Q-fever, RMSF, salmonella, and Lyme’s disease was sent to evaluate for secondary hemophagocytic lymphohistiocytosis (HLH). A liver biopsy was also obtained. Lack of clinical and laboratory improvement prompted us to review our empiric coverage. The clinical picture was thought to be secondary to an infection, therefore, we had narrowed our antibiotics to only doxycycline for non-enteric gram-negative bacilli. We also utilized Isabel Healthcare Differential Diagnosis (DDX) Tool, which generated ten differential diagnosis including Brucellosis. Our patient later admitted to consuming homemade cheese on her last visit to Mexico. Brucella serology and blood cultures were obtained. Fever resolved 48 hours after doxycycline was initiated. Later, blood cultures grew Brucella spp. Currently, our patient remains symptom-free and all laboratory abnormalities have normalized. DISCUSSION: Sepsis guidelines recommend empiric coverage for common pathogens with no clear advice on uncommon infectious agents. A detailed travel and social history are crucial, especially in patients who do not improve on empiric broad spectrum antibiotics. In addition, medical decision making relies on pattern recognition of illness scripts accumulated over time. Historically, we refer to textbooks for the DDX of each symptom. Nowadays, we have more sophisticated DDX generators that incorporate epidemiological data, clinical and laboratory findings to create a DDX list. In a study, the pooled accurate diagnosis retrieval rate for DDX tools was as high as 0.70. CONCLUSIONS: It is imperative to identify significant and clinically relevant data. DDX generators may be useful resources for clinicians and it may also increase the medical knowledge. Reference #1: PMID: 26157077 DISCLOSURES: No relevant relationships by Jose Zabala-Genovez, source=Web Response