Reactions 1680, p225 - 2 Dec 2017 Various toxicities: case report A 53-year-old man developed septic shock, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS) and bacterial sepsis secondary to Capnocytophaga canimorsus infection during treatment with methotrexate and prednisolone [not all routes stated]. Subsequently, he died due to Capnocytophaga canimorsus infection. The man, who had been receiving oral methotrexate 10 mg/week along with low-dose prednisolone 2 mg/day for 5 years as a treatment of rheumatoid arthritis, presented with a 3 day history of fever and dyspnoea. Four days prior to the fever and dyspnoea onset, his pet dog bit him on his left index finger; however, on examination there was no signs of cellulitis and erythema. After the exacerbation of his symptoms, he was hospitalised. At admission, he had had a BP of 63/52mm Hg, HR of 129 beats/min, RR of 40 /min, body temperature of 38.0°C and oxygen saturation of 100%. Laboratory investigations were remarkable for pancytopenia, high-grade inflammatory status and renal impairment. Coagulation studies revealed prolonged prothrombin time and increased fibrin/fibrinogen degradation products. These findings were indicative of a septic shock and DIC. A chest CT scan showed ground glass opacity with consolidation in the sub-pleural regions of the bilateral lower lobes. Thereafter, the man was transferred to the ICU, where he received massive fluid replacement, and was administered a single dose of meropenem. Moreover, he required platelet transfusion and nafamostat [nafamostat mesilate] to treat sepsis-related DIC. Despite massive fluid resuscitation, his hypotension continued. As a result, he received noradrenaline followed by hydrocortisone. On the second day, the intensive treatments did not improve the hypotension, and his respiratory condition worsened. Repeat CT showed progression of consolidations in the bilateral middle and lower lobes and the development of ARDS. Due to the ARDS, he underwent mechanical ventilation. At that time, capnophilic gram-negative rod was identified from his blood cultures. On the basis of clinical course, septic shock, DIC and ARDS secondary to C. canimorsus infection were suspected. However, on the third day, he had pupillary dilation with no light reflex. A head CT demonstrated cerebral haemorrhage and herniation. After a 5 day stay in the ICU, he died. After his death, a species-specific polymerase chain reaction identified C. canimorsus pathogen as the cause of severe sepsis. Author comment: "C. canimorsus infections should be considered in the differential diagnosis of sepsis for immunocompromised hosts following animal bites." "Our case was a rare situation where the subject presented with [methotrexate] associated immunodeficiency in which life- saving procedures were unsuccessful due to septic shock, DIC, and ARDS caused by C. canimorsus infection." Tamura S, et al. Capnocytophaga canimorsus sepsis in a methotrexate-treated patient with rheumatoid arthritis. IDCases 10: 18-21, 5 Aug 2017. Available from: URL: http://doi.org/10.1016/j.idcr.2017.08.002 - Japan 803284507 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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