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.