A 77-year-old male with multiple comorbidities including a history of left adrenal mass, disseminated histoplasmosis status post left adrenalectomy and left nephrectomy, chronic pleural effusions, renal failure on hemodialysis, chronic obstructive pulmonary disease, history of perforated diverticulitis–status post colectomy in the recent past, presented to the emergency department with pain in the left side of his abdomen for the last 18 hours. Patient stated that he worked in his garage throughout the day and as the day concluded, he noted some vague left-sided discomfort. He stated the pain seemed to be positional and seemed to be worsened by deep breathing or coughing. He denies any known injury that occurred during the day. Patient has had some chronic shortness of breath and cough due to ongoing histoplasmosis and a chronic left pleural effusion. Patient stated that approximately 03:00 that morning he was awakened with some worsening pain. Again he stated the pain seemed to be positional and worsened by deep breathing or coughing. Patient stated he felt somewhat bloated and had a bowel movement at that time which he described as a normal bowel movement. Patient stated that his discomfort had persisted and it has led to his presentation. A CT scan of his abdomen/pelvis was subsequently performed given his history of perforated diverticulitis. This was read as non-acute, though the lung bases did show possible pneumonia. He was then discharged with instructions to follow up with his primary care provider. When he was taken back by his family, he was reported to be unresponsive in the car and was quickly brought back by the family to a different emergency department. Further history elicited from the family revealed that the patient lived with 2 cats, without any reported bites, scratches, or wounds.
On admission, patient was noted to be unresponsive and subsequently was intubated. His arterial blood gas would show pH 7.10, PCO2 69, PO2 65, saturations at 82% on 100% FiO2. Laboratory workup was significant for leukocytosis of 30.7 k/uL, BUN 51 mg/dL, creatinine 2.8 mg/dL (baseline 1.4), AST 522 U/L, ALT 627 U/L, alkaline phosphatase 77 U/L, and total bilirubin 1.4 mg/dL. Blood cultures from the first hospital visit would later result positive for Pasteurella multocida. Likewise, a bronchoalveolar lavage performed during hospitalization also later resulted positive for Pasteurella multocida. The patient was hypotensive with blood pressures measuring 70s/40s and he was started on norepinephrine and vancomycin piperacillin/tazobactam. Fluid resuscitation was also performed with 2.2 L of crystalloid fluid provided. Later the patient developed evidence of shock liver, acute kidney injury, profound lymphocytosis with neutropenia, and severe lactic acidosis. Nephrology, hematology, surgery, infectious disease services were consulted. As the patient’s condition was deteriorating, piperacillin/tazobactam and vancomycin were discontinued and meropenem instead started. The patient showed slow improvement during his stay in the ICU, and was gradually able to be weaned from vasopressors and mechanical ventilation. Antibiotics were switched to ampicillin/sulbactam, and the patient would be transferred to a medical/surgical unit from ICU. He was found to have a lower extremity deep vein thrombosis during this time, and an IVC filter was placed, given marked thrombocytopenia. Unexpectedly and after a few days in the medical/surgical unit, the patient once again developed respiratory failure and severe hypotension. The patient was reintubated and taken back to the ICU. Despite aggressive measures including continuous renal replacement therapy and vasopressors, the patient once more reentered a shock state with multiorgan dysfunction. Escalating pressor requirements, CRRT, mechanical ventilatory support were all maximally applied. A family meeting was held and the family decided to pursue comfort care for the patient. The patient expired two days after the decision to pursue comfort care through pulseless electrical activity and asystole.