Case Presentation: A 61-year-old male was admitted to the hospital due to multiple bouts of non-bloody emesis and shock. Symptoms began with progressive lightheadedness, fatigue, and worsening jaundice. He denied any fevers, abdominal pain, or diarrhea. His past medical history was significant for alcoholic liver cirrhosis. He last drank alcohol 6 months prior and had recently relocated to his sister’s house. Vital signs showed a temperature of 36.4 degree Celsius, a heart rate of 71, a blood pressure of 72/42, and no tachypnea or hypoxemia. His physical exam was notable for scleral icterus, jaundice, numerous spider angiomas and a distended but nontender abdomen. His neurologic, cardiac and pulmonary exams were unremarkable. His white count was 24.2 cells per cubic millimeter. His hemoglobin, platelets, and International Normalized Ratio were at his baseline of 9.6 gram per deciliter, 69,000 per microliter, and 2.6, respectively. His total and direct bilirubin were 9.5 and 4.5 milligram per deciliter respectively. His blood cultures grew gram-negative rods which were speciated as Pasteurella multocida. After further questioning, his family reported that one week prior to presentation, his sister’s cat bit his right hand deep enough to draw blood. On re-examination, a small puncture wound was noted on the volar aspect of his right hand without erythema, tenderness, or warmth. His antibiotics were switched to ampicillin and sulbactam. His hospital course was complicated by multiorgan failure and unfortunately the patient was transitioned to comfort care and died.
Discussion: Pasteurella multocida is a gram-negative rod that is part of the normal upper respiratory tract flora of animals with cats and dogs having the highest carrier rates. Humans become infected through bites or scratches from colonized animals. Cats are more likely to transmit infection because their bites penetrate deeper than those from other animals. For these reasons, hospitalists should have Pasteurella at the top of the differential for septic patients with any suspected cat wounds. Pasteurella usually causes soft tissue, bone, or joint infections, but bacteremia can develop from a localized infection in immunocompromised individuals, like this patient with end stage liver disease. Pasteurella is susceptible to several antibiotics and no clinical trials evaluating different antibiotics recommend a specific regimen. The mortality rate in Pasteurella bacteremia can be as high as 30 percent.
Conclusions: Pasteurella multocida is a rare but life-threatening cause of septic shock in patients with liver cirrhosis. This case exemplifies the importance of taking a thorough social history, especially in immunocompromised patients presenting with shock, to generate an inclusive differential diagnosis and appropriate treatment regimen.