Case

A 46-year old Caucasian male with a history of intravenous drug abuse, hypertension and traumatic
splenectomy (after a motor vehicle accident 12 years prior), was brought to a hospital with altered
mental status for the past one day, he reportedly had on off fever, gum bleeding and ecchymoses 4
days ago HE was also a chronic smoker and had a history of noncompliance to vaccinations. On
arrival to the emergency department, he had multiple episodes of coffee ground emesis and tarry
colored stools.

On examination, he was febrile up to a temperature 40 degrees C and persistently hypotensive with

blood pressure (BP) 70/20, and heart rate 70 beats per min (bpm). A petechial rash was noted
initially on his face, but then rapidly became generalized spreading to his arms, legs and trunk .He
also had multiple needle track marks on both upper extremities. Digital rectal examination was
guaiac positive. Gastric lavage was also significant for 800cc coffee ground fluid.

There was no peripheral lymphadenopathy. Chest was clear to auscultation and the liver and the
spleen were not palpable. Examination of the lower extremities showed confluent ecchymoses
involving the left ankle, and the posterior of both
Thighs . Chest X-ray (CXR) did not show any evidence of cardiopulmonary disease. Head
computer tomography (CT) without contrast did not reveal any abnormalities.

Laboratory data showed a lactic acid of 8.5 and also evidence of coagulopathy consistent with
DIC.

Laboratory evaluation revealed hemoglobin of 10 g/dL (normal: 14 to 16 g/dL), platelets of 107 ×

103/μL (normal: 150 to 400 × 103/μL), and total leukocytes of 20.1 × 103/mm3(normal: 4.0 to 11
× 103/mm3). His prothrombin time was 22.8 seconds (normal: 11.5 to 15.5 seconds), and his INR
was 1.92 (normal: 1 to 1.25). The activated partial thromboplastin time (aPTT) was 45 seconds
(normal: 25.2 to 36 seconds), the serum fibrinogen was <0.30 g/L (normal: 1.3 to 3.5 g/L), and the
plasma concentration of d-dimers was >4 μg/mL (normal:≤0.40 μg/mL). Plasma levels of factors
V, VII, XIII, and activated protein C as well as serum creatinine and liver function tests were
within normal limits. Examination of a blood smear was consistent with a normochromic,
normocytic anemia, with reduced platelets and large forms, and possible blasts with folded nuclei.
Shortly after admission, all coagulation parameters worsened (INR=2.92; PT=32 seconds;
aPTT=55 seconds) and the ecchymoses increased in number and extent.

Blood cultures revealed gram negative rods on gram stain.

The patient was managed as DIC secondary to Sepsis and was givwn supportive therapy.
He did not respond to aggressive intravenous fluid resuscitation, so pressors had to be started. He
also required intubation for airway protection. Vancomycin, cefepime and metronidazole were
empirically started

Despite prompt antibiotic treatment and administration of fresh frozen plasma and platelets, she
passed away on the day of admission. Soon after her demise, the blood cultures
resulted Acinetobacter baumannii. The microbiological result was confirmed that the species was
pansusceptible. Family declined autopsy.

Learning objectivves:

1. Discuss briefly the immunologic responses to infection.

A. Innnate and adaptive immunity
B. Role of antibodies and complement system
C. Immune response to a gram negative bacterial infection
2. Summarize the normal processes involved in
A. Hemostasis
B. Anticoagulation and fibrinolysis
3. Explain the physiologic processes that led to the following conditions:
A. Shock and altered mental status
B. Abnormalities in coagulation parameters
C. Bleeding signs
4. Create a concept map showing the different pathophysiologic concepts involved in the disease
that ultimately resulted to the demise of this patient. List down in sequence all the physiological
processes that were disrupted that led to the signs, symptoms presented, as well as laboratory
results obtained.

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