Case Presentation: A 38-year-old woman with sickle cell disease, right heart failure due to pulmonary hypertension, and adrenal insufficiency was admitted for septic shock due to MRSA bacteremia. She was treated with antibiotics with initially good response. Her MICU course was complicated by acute decompensated heart failure leading to acute hypoxic respiratory failure. This improved with BIPAP and diuresis and she was transferred to the floor. Days later, she became hypotensive with worsening mental status, acute liver injury, acute kidney injury and diffuse intravascular coagulation. The patient was transferred to the MICU for undifferentiated shock. In the MICU, her shock was presumed cardiogenic with a possible septic component. She was maintained on broad spectrum antibiotics. US abdomen was pursued given worsening LFTs and bilirubin. This showed gallbladder hydrops, with the gallbladder measuring 12.6 cm x 5.1 cm. A hepatobiliary scan was suggested to evaluate for cholecystitis. Previous US about 1-week prior showed similar gallbladder wall thickening so further work-up was deferred. The patient’s shock was progressive despite antibiotic therapy, and she died 5 days later with family present.
Discussion: A diagnostic error was thought to be at least likely in this case resulting from a failure to act on a result—the finding of possible cholecystitis with gallbladder hydrops on US abdomen. Source control is an imperative part of the management of sepsis and septic shock. In this case, further investigation of a possible biliary sepsis with additional imaging and/or general surgery evaluation was likely warranted. While the patient was likely too sick for cholecystectomy, a percutaneous biliary tube might have provided source control and, ultimately, led to improvement or resolution of her septic shock. Opposing this theory is the fact that the patient was already experiencing multiorgan failure at that point and may not have tolerated any procedures, including percutaneous biliary tube. Benefit from any intervention, other than empiric broad spectrum antibiotics, may have been seen as negligible. Unfortunately, there is little documentation on the approach or thought processes regarding the infectious component of the patient’s shock in this case.
Conclusions: In patients admitted to the MICU with suspicion of shock, a standardized approach that involves clear documentation of infectious sources remains an imperative component of patient care.