Retrievable Günther Tulip filter complicated by sepsis and retroperitoneal hemorrhage: successful management by filter retrieval

Citrobacter freundii induces sepsis with new-onset status seizure in an adult: A case report and literature review

RATIONALE

Sepsis with brain abscess induced by Citrobacter freundii in adults has rarely been reported and is extremely pathogenic with a high mortality rate. Early diagnosis of the infection still remains challenging.

PATIENT CONCERNS

A 27-year-old woman was transferred to our emergency department for fever, status seizure and refractory hypotension. Administration of midazolam, propofol and sodium valproate could not attenuate the seizure except for the addition of vecuronium. The blood white blood cell count was 42.91 (109/L) with 80% neutrophils, and procalcitonin was 22.46ng/mL.

DIAGNOSES

Both deoxyribonucleic acid and ribonucleic acid of C freundii were detected in blood by metagenomic next-generation sequencing of pathogens,the diagnosis of septic shock and brain abscess caused by C freundii was highly suspected.

INTERVENTIONS

On day 1, antibiotics of cefoperazone sodium and sulbactam sodium 6g/day, immunoglobulin, and hydrocortisone were used with suspected septic shock. Continuous renal replacement therapy was used to eliminate excessive lactate, ammonia, myohemoglobin and creatinine. On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, antibiotics were adjusted to meropenem intravenously 3g/day.

OUTCOMES

On day 2, a brain computed tomography scan revealed multiple patchy slightly low densities in the brain, she died on day 3.

LESSONS

Clinicians should consider the possibility of brain abscess when evaluating a patient with new-onset dizziness, fever, seizure, or other neurologic symptoms or signs, especially for patients whose mental status changes. metagenomic next generation sequencing and resistance genes could be considered when cerebrospinal fluid or blood results are negative and clinical manifestations are highly suspected of infection or when the treatment time is limited.

Inferior vena cava filters

Venous thromboembolism (VTE) remains a common disease with significant clinical impact upon our patients. Diagnostic challenges occur because of the nonspecific nature of the presenting symptoms. The advent of multidetector computed tomography, methods to stratify patients into VTE risks (low, intermediate, high) along with serological assays (D-dimers), have helped direct patients through proper workup and into conclusive diagnosis. In most cases, standard medical therapy for VTE is anticoagulation therapy (OAT). In situations where standard OAT is either contraindicated or complications result from that therapy, insertion of inferior vena cava (IVC) filters is considered. Recent reports suggest that although IVC filters are able to prevent pulmonary emboli (PE) in the short and intermediate term, there appear to be long-term consequences including excess recurrent deep venous thombosis (DVT and IVC/filter occlusions). Recognition of the time sequence of IVC filter benefits and complications has encouraged development of optional IVC filters, which can be left in place indefinitely or removed usually before certain time constraints. This article will attempt to address the timing of IVC filter placements to protect patients from significant PE.

Vena cava filters and inferior vena cava thrombosis

OBJECTIVE

Retrievable vena cava filters (R-VCF) are a recent addition to the therapeutic armamentarium for the prevention of pulmonary embolism. However, unlike permanent vena cava filters (P-VCF), outcomes data are limited regarding complication rates.

METHODS

This was a retrospective comparative analysis of consecutive patients undergoing placement of R-VCF vs P-VCF at Wake Forest University School of Medicine from January 2000 to December 2004. Data collected included demographics, procedural specifics, filter type, indications, and complications. Summary data are expressed as number (percentage) or mean +/- SD. Continuous and categorical variables were analyzed by using t and Fisher exact testing, as appropriate. Four additional patients with vena cava thrombosis were also referred to our institution for treatment during the study period, all with opposed biconical VCFs (OptEase and TrapEase filters) recently placed at other facilities. This last group of patients is described but not included in the analysis.

RESULTS

A total of 189 VCF (165 P-VCF and 24 R-VCF) cases were examined. No significant differences in VCF groups were observed according to age, documented hypercoagulability, or concomitant anticoagulation. Significant differences were observed according to sex (30.3% of P-VCF vs 62.5% of R-VCF patients were female), morbid obesity (4.2% of P-VCF vs 25% of R-VCF patients), active malignancy (20% of P-VCF vs 41.7% of R-VCF patients), and indication for VCF placement. Over a median follow-up of 8.5 months, no case of significant hemorrhage, no VCF migration, and four cases of vena cava thrombosis were observed. Vena cava thrombosis was observed more frequently in the presence of R-VCF when compared with P-VCF (12.5% vs 0.6%; P = .007). All observed vena cava thromboses were associated with severe clinical symptoms and occurred in patients who received opposed biconical VCF designs.

CONCLUSIONS

In our experience, both P-VCF and R-VCF can be placed safely. Among both permanent and retrievable devices, however, opposed biconical designs seem to be associated with an increased risk for vena cava thrombosis. Although causative factors remain unclear, filter design and resultant flow dynamics may play an important role, because all episodes of vena cava thrombosis occurred in patients with a single-filter design.