Septic Shock Secondary to β-hemolytic Streptococcus-induced Necrotizing Fasciitis treated with a Novel Cytokine Adsorption Therapy

Abstract

Introduction

Numerous animal studies and preliminary data from a clinical trial in septic patients demonstrated that a decrease in blood cytokine levels using an extracorporeal cytokine filter (CytoSorb™) can effectively attenuate the inflammatory response during sepsis and possibly improve outcomes.

Methods

A 60-year-old female was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection which progressed to necrotizing fasciitis. All diagnostic criteria for SIRS were evident with additional proven infection from β-hemolytic streptococcus. On admission to the ICU, the patient presented a full picture of multiple organ dysfunction syndrome due to septic shock including kidney failure, lung failure as well as thrombocytopenia, metabolic acidosis, and arterial hypotension.

Results

After one day on mechanical ventilation and an IL-6 level of 70 000 pg/ml the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 to 66 pg/ml and an overall improvement of the patient's condition. Despite the necessity of enucleation, the patient was successfully stabilized until control of the surgical infectious source was achieved. Importantly, treatment was safe and well-tolerated, without any adverse events.

Conclusions

This is the first report of the clinical application of CytoSorb hemoadsorption in combination with a CRRT in a patient with septic shock. CytoSorb as described was able to significantly reduce IL-6 plasma levels and decrease vasopressor need while no adverse and device-related events occurred. CytoSorb seems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.

Keywords

Sepsis Septic shock Necrotizing fasciitis Cytokine adsorption Multiorgan failure

Get full access to this article

View all access options for this article.

References

Rimmelé

, Kellum

J.A.

Clinical review: blood purification for sepsis. Crit Care. 2011; 15(1): 205. Published online February 16, 2011.

Cole

, Bellomo

, Journois

, Davenport

, Baldwin

, Tipping

High-volume haemofiltration in human septic shock. Intensive Care Med. 2001; 27(6): 978–986.

Honore

P.M.

, Jamez

, Wauthier

. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med. 2000; 28(11): 3581–3587.

Cole

, Bellomo

, Hart

. A phase II randomized, controlled trial of continuous hemofiltration in sepsis. Crit Care Med. 2002; 30(1): 100–106.

Payen

, Mateo

, Cavaillon

J.M.

, Fraisse

, Floriot

, Vicaut

; Hemofiltration and Sepsis Group of the Collège National de Réanimation et de Médecine d'Urgence des Hôpitaux extra-Universitaires. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med. 2009; 37(3): 803–810.

Heering

, Morgera

, Schmitz

F.J.

. Cytokine removal and cardiovascular hemodynamics in septic patients with continuous venovenous hemofiltration. Intensive Care Med. 1997; 23(3): 288–296.

Angus

D.C.

, Linde-Zwirble

W.T.

, Lidicker

, Clermont

, Carcillo

, Pinsky

M.R.

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001; 29(7): 1303–1310.

Engel

, Brunkhorst

F.M.

, Bone

H.G.

. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med. 2007; 33(4): 606–618.

Fisher

C.J.

Jr. , Agosti

J.M.

, Opal

S.M.

; The Soluble TNF Receptor Sepsis Study Group. Treatment of septic shock with the tumor necrosis factor receptor: Fc fusion protein. N Engl J Med. 1996; 334(26): 1697–1702.

10.

Abraham

, Wunderink

, Silverman

. Efficacy and safety of monoclonal antibody to human tumor necrosis factor alpha in patients with sepsis syndrome. A randomized, controlled, double-blind, multicenter clinical trial. TNF-alpha MAb Sepsis Study Group. JAMA. 1995; 273(12): 934–941.

11.

Fisher

C.J.

Jr. , Slotman

G.J.

, Opal

S.M.

; IL-1RA Sepsis Syndrome Study Group. Initial evaluation of human recombinant interleukin-1 receptor antagonist in the treatment of sepsis syndrome: a randomized, open-label, placebo-controlled multicenter trial. Crit Care Med. 1994; 22(1): 12–21.

12.

Peng

Z.Y.

, Carter

M.J.

, Kellum

J.A.

Effects of hemoadsorption on cytokine removal and short-term survival in septic rats. Crit Care Med. 2008; 36(5): 1573–1577.

13.

Kellum

J.A.

, Song

, Venkataraman

Hemoadsorption removes tumor necrosis factor, interleukin-6, and interleukin-10, reduces nuclear factor-kappaB DNA binding, and improves short-term survival in lethal endotoxemia. Crit Care Med. 2004; 32(3): 801–805.

14.

Peng

Z.Y.

, Wang

H.Z.

, Carter

M.J.

. Acute removal of common sepsis mediators does not explain the effects of extra-corporeal blood purification in experimental sepsis. Kidney Int. 2012; 81(4): 363–369.

15.

Spittler

, Razenberger

, Kupper

. Relationship between interleukin-6 plasma concentration in patients with sepsis, monocyte phenotype, monocyte phagocytic properties, and cytokine production. Clin Infect Dis. 2000; 31(6): 1338–1342.

16.

Peng

Z.Y.

, Carter

M.J.

, Kellum

J.A.

Effects of hemoadsorption on cytokine removal and short-term survival in septic rats. Crit Care Med. 2008; 36(5): 1573–1577.

17.

Kellum

J.A.

, Kong

, Fink

M.P.

; GenIMS Investigators. Understanding the inflammatory cytokine response in pneumonia and sepsis: results of the Genetic and Inflammatory Markers of Sepsis (GenIMS) Study. Arch Intern Med. 2007; 167(15): 1655–1663.

18.

Osuchowski

M.F.

, Welch

, Siddiqui

, Remick

D.G.

Circulating cytokine/inhibitor profiles reshape the understanding of the SIRS/CARS continuum in sepsis and predict mortality. J Immunol. 2006; 177(3): 1967–1974.

19.

Pinsky

M.R.

, Vincent

J.L.

, Deviere

, Alegre

, Kahn

R.J.

, Dupont

Serum cytokine levels in human septic shock. Relation to multiple-system organ failure and mortality. Chest. 1993; 103(2): 565–575.