A complicated case of sepsis

A 71-year old woman was admitted because she was found confused at her home. Her clinical history was remarkable for depression, hypertension, type 2 diabetes with organ damage and diabetic wound in the left leg. A new onset atrial fibrillation was found with hyperglicemia (glucose 307 mg/dL; normal values 60– 110), low TSH (0.24 mcU/mL, n.v. 0.35–4.50) and FT3 2.3 pg/mL (n.v. 2.30–4.20). A CT scan ruled out acute brain lesions. Few hours later the patient returned spontaneously to sinus rhythm. Delirium resolved in two days with satisfactory glycemic control. On day 6, the patient developed fever that the next day increased to 39 8C with reduced vigilance. C-protein was > 25 mg/dL (n.v. < 1) and a chest x-ray was negative. Therapy with piperacillin/tazobactam was introduced. On day 9, the patient was still febrile and became comatose, therefore meropenem + teicoplanin and dexamethasone were introduced. Brain CT was repeated (negative) and a lumbar puncture was attempted without success. Culture tests documented sepsis due to Staphylococcus aureus methicillin susceptible. On day 12, fever disappeared and the patient gradually recovered consciousness, but the neurological exam showed quadriplegia, reduction in deep tendon reflexes with normal sensibility. Myolysis indices were increased [myoglobin 2697 ng/ mL, n.v. < 70; creatine phosphokinase (CPK) 822 UI/L, n.v. < 195]. Antibodies against acetylcholine receptor were negative and the