Introduction:
There is a well-established connection that cirrhosis has a negative
outcome on a patient’s health. Patients with cirrhosis often have
complications including, but not limited to portal hypertension,
splenomegaly, increased risk of bleeding, risk of encephalopathy among
other complications which lead to increases in morbidity and
mortality1. Although these complications are well
established, cirrhosis-associated immune dysfunction (CAID) is not as
often considered in the setting of the septic patient. Sepsis and septic
shock can be identified by hallmarks such as, temperature, hemodynamic
instability, heart rate and leukocytosis. Physiologic changes of
cirrhosis can compromise the identification of septic shock. Patients
with cirrhosis live in a vasodilatory state secondary to nitric oxide
release from the cirrhotic liver2. Furthermore,
patients are in a hyperdynamic state that can alter
thermoregulation3. Sequestration of blood cells in
patients with cirrhosis and associated portal hypertension can cause
leukopenia in the setting of spleen sequestration4.
CAID predisposes patients to diminished levels of innate and acquired
immunity5. Septic shock associated with bloodstream
infections can occur in up to 21% on cirrhotic patients, ten-fold
higher than patients without cirrhosis6. Indicators of
severe infection can be masked in a patient due to the altered
physiology of cirrhosis. Hemodynamic instability, altered
thermoregulation, and skewed white blood cell counts in the septic
patient can lead to a critical clinical delay in the identification of
the septic patient.
Acinetobacter baumannii is a gram-negative bacillus that is known as an
opportunistic infection, typically found in patients with prolonged
hospital stays7,8. Acinetobacter baumannii often
colonizes the oropharynx, and is well-established as a MDR organism9. Cirrhotic patients with CAID infected with a MDR
organism such as Acinetobacter baumannii have increased rates
mortality10.
Our case is a patient with suspected cirrhosis with no significant
medical history but with a history of extensive alcohol consumption. The
peculiarity of this case was the self-isolation status of the patient
from the Covid-19 pandemic. Family stated the family had not left the
house for nearly two years due to concern of Covid-19 exposure. This
case provokes the question; how this patient acquired such a rare
bacterial infection with no predisposing history or exposure. This case
highlights the natural physiologic changes due to cirrhosis and shows
that physicians need to stay vigilant in anticipating severe sepsis from
rare organisms in this high-risk patient population.