Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Thrombocytopenia of Unclear Etiology: Immune-Mediated Thrombocytopenia in the
Septic Patient
Thim, M., OMSIII; Boni, C., D.O.
Saint Michael’s Medical Center, Department of Internal Medicine, Newark, NJ
Introduction: Thrombocytopenia is a common clinical issue and can be attributed to a wide
range of etiologies. Our patient presented on day one with acute renal failure with obstructive
uropathy and developed an isolated thrombocytopenia on day two. Consequentially, the
patient was suspected to have immune mediated thrombocytopenia, and was started on
gammaglobulin and steroids. Later on day two, urinalysis and urine culture results prompted
diagnosis of urosepsis secondary to pyelonephritis due to gram-negative, extended spectrum
beta lactamase producing rods.
Case: A.D., a 59-year-old-male with a past medical history only significant for prostate
carcinoma status post radial robotic prostatectomy, presented at the PMD three days post ER
visit with continued complaints of weakness, body aches, as well as nausea and vomiting.
This is combination with the patient’s acute rise in creatinine (1.6 from baseline of 0.89),
discovered from ER lab workup, prompted PMD to direct admit the patient to SMMC for right
flank pain and acute kidney injury workup. On direct floor admission, vital signs were
temperature 97°F, BP 78/56, heart rate 78, respiratory rate 18, and pulse ox 96%. Laboratory
workup was significant for: leukocytes18.9 k/uL (90% segs, 2% lymphocytes), BUN 114
mg/dL, Cr 8 mg/dL, platelets of 24 k/uL. Acute renal failure prompted transfer to MICU, where
obstructive uropathy was diagnosed status post renal ultrasound. Foley catheter was placed.
The patient was given IV fluids, 1 Amp NaHCO 3 , Zofran prn for nausea, and cefepime. Day
two vitals were temperature of 98.6 °F, respiratory rate of 28, heart rate of 83, and BP of
92/58. Laboratory workup was significant for WBCs 2.3, hemoglobin14.1, hematocrit 39.7,
BUN 126, creatinine 6, and platelets 18. CT Abdomen/Pelvis without contrast confirmed mild
to moderate right obstructive uropathy due to a 4 mm calculus proximal to the right ureter.
Urinary stent placement as well as emergency hemodialysis for severely elevated BUN/Cr
was completed. Urinalysis was significant for cloudy urine, with trace ketones, +3 blood, +2
protein, +3 leukocyte esterase, too numerous to count WBCs, and RBC’s, moderate bacteria,
as well as +2 sulfosalicyclic acid. Urine culture confirmed growth of gram-negative, extended
spectrum beta-lactamase organisms, confirming the diagnosis of urosepsis. Subsequent
isolated thrombocytopenia work up revealed fibrinogen 611 mg/dL and D-Dimer 1 ng/mL, LDH
54, haptoglobin 190, bilirubin studies within normal limits, hepatitis panel negative, HIV
negative, HCV negative, and platelet morphology was normal. As a result, the patient was
treated for immune mediated thrombocytopenia with IV gammaglobulin and steroids as well
as serial platelet transfusions. The patient’s urosepsis was treated with meropenem.
Discussion: Based on the patient’s history, physical exam, CBC, platelet morphology, and
poor response to platelet transfusion, a presumptive diagnosis of immune-mediated
thrombocytopenia secondary to severe sepsis was made for the patient’s isolated
thrombocytopenia. Due to the patient’s severe septic state, the exact etiology of the isolated
thrombocytopenia is highly questionable. Additionally, in the setting of acute kidney failure,
we must question whether or not the use of IV gammaglobulin and steroids were appropriate
in this patient. Furthermore, due to the lack of consensus on the diagnostic criteria and the
indications for steroid therapy in “critical illness-related corticosteroid insufficiency (CIRCI),”
such as in the septic patient, the role of severe, isolated thrombocytopenia may have some
utility as a biologic marker for indications or contraindications for steroid therapy in CIRCI.