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An Unusual Case of Typhlitis in a Post-Partum Female
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A5198 - An Unusual Case of Typhlitis in a Post-Partum Female
Author Block: A. S. Jhand1, A. Ahmad1, K. Keeley2, R. Norris1, R. Vivekanandan3; 1Internal Medicine, Creighton University School of Medicine, Omaha, NE, United States, 2Creighton University School of Medicine, Omaha, NE, United States, 3Infectious Diseases, Creighton University School of Medicine, Omaha, NE, United States.
INTRODUCTION: Sepsis is a leading cause of mortality in pregnancy and post-partum period. Despite of ongoing initiatives by various professional organizations aimed at spreading awareness and improving early diagnosis and treatment, the death rate from sepsis has been on a rise in the post-partum period in the United States.
CASE PRESENTATION: A 27-year old G4P3L3A0 African-American female presented to our hospital in labor and developed post-partum hemorrhage after delivery requiring emergent hysterectomy. Moreover, she developed shock requiring transient vasopressor support and mechanical ventilation. Lab work revealed a significant drop in hemoglobin and platelet count for which she was resuscitated aggressively with blood transfusions. On day 2, she developed fevers and leukocytosis with neutrophilic predominance and left shift (WBC count of 28.3 k/ul). Sepsis workup was undertaken and she was started on Piperacillin/Tazobactam. Despite being on broad spectrum coverage, WBC count continued to rise and on day 5 reached 41.5 k/ul. Additionally, procalcitonin also continued to trend upwards (5.23 ng/ml on day 2 to 22.79 ng/ml on day 5). Blood and urine cultures were negative and chest radiograph was without any infiltrates/consolidation. A Computed Tomography (CT) scan of the abdomen and pelvis was performed and a circumferential thickening of the cecum and ascending colon was seen consistent with typhlitis. Antibiotic coverage was changed to Meropenem, Vancomycin and Clindamycin. Over the next few days her WBC count improved and she was transitioned to oral Amoxicillin/Clavulanate. At a two week follow up patient was clinically doing much better and WBC count improved to 15.2 k/ul.
DISCUSSION: A relative state of immunosuppression in pregnancy may predispose to Typhlitis which can be potentially lethal. Our patient lacked clinical features such as abdominal pain or tenderness, however imaging confirmed it as the potential source of sepsis. Physiological changes of pregnancy, for example elevated temperature and changes in systolic blood pressure can obscure the signs and symptoms of sepsis in the obstetric population. The traditional scoring systems used to identify patients at risk for sepsis and septic shock including SIRS, MEWS and REMS do not take these physiological changes in consideration and are thus inaccurate in the obstetric population. There is an urgent need to develop and validate, risk stratification system that addresses sepsis in the obstetric population. Until then, clinicians need to have a high index of suspicion for sepsis while caring for pregnant and post-partum patients.
Author Block: A. S. Jhand1, A. Ahmad1, K. Keeley2, R. Norris1, R. Vivekanandan3; 1Internal Medicine, Creighton University School of Medicine, Omaha, NE, United States, 2Creighton University School of Medicine, Omaha, NE, United States, 3Infectious Diseases, Creighton University School of Medicine, Omaha, NE, United States.
INTRODUCTION: Sepsis is a leading cause of mortality in pregnancy and post-partum period. Despite of ongoing initiatives by various professional organizations aimed at spreading awareness and improving early diagnosis and treatment, the death rate from sepsis has been on a rise in the post-partum period in the United States.
CASE PRESENTATION: A 27-year old G4P3L3A0 African-American female presented to our hospital in labor and developed post-partum hemorrhage after delivery requiring emergent hysterectomy. Moreover, she developed shock requiring transient vasopressor support and mechanical ventilation. Lab work revealed a significant drop in hemoglobin and platelet count for which she was resuscitated aggressively with blood transfusions. On day 2, she developed fevers and leukocytosis with neutrophilic predominance and left shift (WBC count of 28.3 k/ul). Sepsis workup was undertaken and she was started on Piperacillin/Tazobactam. Despite being on broad spectrum coverage, WBC count continued to rise and on day 5 reached 41.5 k/ul. Additionally, procalcitonin also continued to trend upwards (5.23 ng/ml on day 2 to 22.79 ng/ml on day 5). Blood and urine cultures were negative and chest radiograph was without any infiltrates/consolidation. A Computed Tomography (CT) scan of the abdomen and pelvis was performed and a circumferential thickening of the cecum and ascending colon was seen consistent with typhlitis. Antibiotic coverage was changed to Meropenem, Vancomycin and Clindamycin. Over the next few days her WBC count improved and she was transitioned to oral Amoxicillin/Clavulanate. At a two week follow up patient was clinically doing much better and WBC count improved to 15.2 k/ul.
DISCUSSION: A relative state of immunosuppression in pregnancy may predispose to Typhlitis which can be potentially lethal. Our patient lacked clinical features such as abdominal pain or tenderness, however imaging confirmed it as the potential source of sepsis. Physiological changes of pregnancy, for example elevated temperature and changes in systolic blood pressure can obscure the signs and symptoms of sepsis in the obstetric population. The traditional scoring systems used to identify patients at risk for sepsis and septic shock including SIRS, MEWS and REMS do not take these physiological changes in consideration and are thus inaccurate in the obstetric population. There is an urgent need to develop and validate, risk stratification system that addresses sepsis in the obstetric population. Until then, clinicians need to have a high index of suspicion for sepsis while caring for pregnant and post-partum patients.
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