Sudden septic shock in rheumatism patients is actually related to acupuncture?

*For medical professionals to read and reference accident and tomorrow, I really don't know which will come first~ I thought it was just a pain, but when there is systemic lupus erythematosus (SLE) combined with fever, the truth is far more complicated than you think.
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Case profile A 64-year-old woman with SLE was admitted to the hospital because of "progressive pain in the right lower neck, swelling and pain in the right shoulder for 3 days, and fever for 1 day"
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 Denies strenuous exercise or contact with any febrile individuals
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 The medical history may seem simple, but as long as it is associated with fever, it is destined to be difficult! Physical examination on admission: body temperature 39.
9°C, pulse 120 bpm, blood pressure 83/47 mmHg, and respiratory rate 26 beats/min
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Right lower neck and shoulder swelling, positive tenderness, and limited right shoulder and neck movement
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There was no obvious cervical lymphadenopathy
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No arthritis and leg edema
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 Auxiliary examination: leukocyte 2810/µl (N: 3900–11000), hemoglobin 8.
8g/dl (N: 13.
5–17.
5g/dl), platelets 613x109/L (N: 150–400x109/L); total bilirubin 4.
29 mg/dl (N: 0.
2–1.
2mg/dl), albumin 2.
6g/dl (N: 3.
3–5.
0g/dl); prothrombin time 14.
6s (N: 9.
5–11.
7s), activated partial coagulation zymogen kinase time 47s (N: 24.
3–32.
7s); blood urea nitrogen 33mg/dl (N: 5–25mg/dl), creatinine 1.
25mg/dl (N: 0.
5–0.
9mg/dl), sodium 126mEq/L (N: 137–153mEq/L), Potassium 3.
4mEq/L (N: 3.
5–5.
3 mEq/L), Creatine Kinase 587U/L (N: 10–160U/L), Lactate: 19.
8mg/dl (N : 3–12 mg/dl); C-reactive protein (CRP) 24.
3 mg/dl (N: < 0.
3 mg/dl) and procalcitonin 42.
53 ng/ml (< 0.
05 ng/ml)
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Urine protein was negative, and immunoglobulin G, lactate dehydrogenase, and thyroid function were normal; chest x-ray and ultrasonography revealed a right-sided pleural effusion
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The pleural effusion was analyzed as exudative effusion, and the culture of pleural effusion was negative for bacteria; CT scan showed a small heterogeneous hypodense lesion in the right lower neck, diffuse edema of the right anterior and lateral chest walls, and fat stranding
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Musculoskeletal ultrasonography revealed a hypoechoic anterior scalene muscle and loss of normal muscle texture
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 What does the wave of CT and ultrasound results mean? There is no time to think about this, because the patient has high body temperature, low blood pressure, CRP and procalcitonin are significantly elevated, and septic shock is now clear, fluid resuscitation, vasopressor, and parenteral empiric antibiotic therapy (cephalosporin) must be given quickly.
Thioxime 2g, q12h; Vancomycin 1g, q12h)
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 On the 5th day of hospitalization, the patient's vital signs were stable, but .
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there was still intermittent low-grade fever, and there was progressive edema of the right upper extremity without erythema
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The patient's mental state was good, and there was no numbness in the right upper extremity, and four blood cultures were negative
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 Seeing this, the doctor's first thought was whether it was deep vein thrombosis, because after a detailed medical history, the patient said that she had SLE 20 years ago, and she had been taking azathioprine 25mg/day last year
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Although anti-dsDNA antibodies, complement C3, C4, anti-cardiolipin antibodies and anti-β2-glycoprotein 1 were all negative on this admission, the disease activity of SLE was low
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But lupus anticoagulant (LAC) positive is not antiphospholipid syndrome, which is characterized by deep vein thrombosis
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Therefore, on day 8, a multi-slice spiral CT was performed, which revealed a broad abscess in the pectoralis major muscle with adjacent fat stranding
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The abscess extends up to the right lower neck (levator scapulae) and mediastinum and down to the right deep chest wall (intercostal muscle)
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Notably, the abscess compresses the superior vena cava and the right subclavian vein, but no evidence of deep vein thrombosis was found (Figure 1)
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Figure 1: CT Results Axial view (A and B) and sagittal view (C) of CT
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(A) Large abscess formed inside the right upper chest wall, especially the pectoralis muscle, also compressed to the right portion of the superior vena cava (star); (B) The abscess was compressed distal to the right subclavian vein (star); (C) ) abscess extending to the right lower neck and mediastinum (star)
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 Although there is no evidence of deep vein thrombosis, but extensive abscess formation, the diagnosis is finally clear, it turned out to be suppurative myositis! Treatment is imminent! The doctor immediately performed drainage and debridement
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good guy! Extensive necrotic tissue was observed in the pectoralis minor and major muscles (Figure 2)
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Figure 2 The diagnosis was further confirmed by the production of methicillin-resistant Staphylococcus aureus in the pus culture of necrotic tissue.
Vancomycin was immediately given anti-infective treatment for 28 days.
At the same time, after 2 weeks of continuous debridement, the patient's symptoms improved significantly, and the first The swelling of the right lower neck and right upper extremity completely disappeared 6 days after the second debridement
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On day 22, the surgical wound was sutured and a drainage tube was placed
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From hospital day 29, antibiotics were changed to oral linezolid (600 mg, q12h)
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Discharged on day 33 of hospitalization
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Prognosis During the follow-up period, the patient's condition remained stable and the drainage tube was removed
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CT examination 3 weeks after discharge showed complete resolution of both the chest wall abscess and the mediastinal abscess
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I can finally stop linezolid
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No recurrence of suppurative myositis was found during the following 3 months of follow-up
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 The patient's condition was twists and turns, and he was in septic shock just after being admitted to the hospital.
A few days after the rescue and treatment, a new moth appeared.
Combined with the patient's own history of SLE for many years, the occurrence of infection really made the doctor's heart skip a beat! Why did this patient have such a serious infection? Low immunity is the original sin, is acupuncture adding fuel to the fire? SLE is a chronic autoimmune disease in which patients are susceptible to infection due to an impaired immune response, which is related to the disease itself
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As the disease progresses, immune overactivation damages multiple organs in SLE patients, resulting in compromised pathogen defense mechanisms
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In addition to the disease itself, immunosuppressive agents used to treat SLE, such as steroids and cyclophosphamide, are known to predispose SLE patients to infection
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Risk factors for infection are active lupus status, hypocomplementemia, use of high-dose steroids and immunosuppressants, fever, elevated erythrocyte sedimentation rate and CRP, and abnormal white blood cells (<4×109/L or >10×109/L) and albumin decreased
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Combined with the patient's history of SLE for many years, the long-term use of the immunosuppressant azathioprine, and the fact that the patient had acupuncture on the shoulder and neck before the onset of the disease (if the operation is performed in an informal clinic, infection is likely to occur), various risk factors are clustered.
, make the body that is not strong even worse! Suppurative myositis: A "death" trilogy? Knowing the cause of the infection, what is the disease of suppurative myositis? Suppurative myositis is an infection that primarily affects skeletal muscle, typically presents as a localized abscess, and is more common in tropical countries
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Patients with diabetes, hematological malignancies, chronic renal failure, asplenia, HIV infection, autoimmune diseases, and those receiving chemotherapy or immunosuppressive drugs are often susceptible to infection
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90% of cases are mainly caused by Staphylococcus aureus
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Suppurative myositis usually involves a single muscle, but it is not uncommon to involve multiple muscles
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The most common site of infection is the thigh muscle, but other muscles, including the forearm, sternocleidomastoid, and intercostal muscles, are occasionally affected
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Prompt diagnosis of suppurative myositis in patients with SLE is challenging not only because of its nonspecific features but also because of its resemblance to SLE episodes and inflammatory myositis
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Chest wall involvement is an uncommon condition, and of the 25 reported cases of SLE with suppurative myositis in the available literature, only 1 involved the chest wall
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 It has three clinical stages: The first stage is an aggressive stage, including muscle pain with edema, low-grade fever and general malaise
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Patients should also be concerned for thrombosis, hematoma, muscle strain, and osteomyelitis
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The second stage is the suppurative stage, where patients experience severe muscle tenderness and swelling, high fever, and other severe systemic symptoms
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At this stage, abscess formation can be detected and most cases are diagnosed clinically at this stage
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However, SLE patients may also lack specific signs and symptoms and atypical presentations at this stage
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If treatment is delayed, the infection can spread and progress to the final stage, which is also the most severe
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Patients often experience bacteremia, septic shock, acute renal failure, multiple abscesses, and even death
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 The differential diagnosis should not forget that the patient presented with fever, right lower neck pain, and progressive swelling of the right upper extremity, but no erythema, which is similar to the symptoms of deep vein thrombosis, and also needs to be differentially diagnosed with lymphangitis
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Table 1.
Differential diagnosis of unilateral extremity edema for external venous pressure, deep vein thrombosis, and lymphangitis in patients with
SLE
†Only 4%-10% of DVTs are located in the upper extremities
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In large cohort studies, 20%–30% of patients with APS were found to have lower extremity deep vein thrombosis
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‡86% and 19% of patients with DVT experienced pain
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§Fever may be undetectable in clinical stage 1 and frequently observed in clinical stage 2, usually 10-21 days after symptoms first appear
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¶32% (21/66) of LA and/or anticardiolipin antibody (aCL)-positive patients had deep vein thrombosis
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As mentioned in the above table, the patient's diagnosis was clear, and the symptoms were completely relieved after debridement and drainage and anti-infective treatment, which once again proved that the diagnosis was correct! Experience In children with SLE, suppurative myositis is extremely rare, with a prevalence of only 0.
35% (1/289)
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However, the prevalence of suppurative myositis in adult SLE patients remains unclear
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Due to the unfamiliarity of doctors, the diagnosis of suppurative myositis is sometimes delayed or even missed
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Any adverse condition can lead to increased complications and morbidity
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Therefore, timely diagnosis of suppurative myositis in SLE patients is challenging
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Imaging evaluation, including ultrasonography, CT, and MRI, is important for its diagnosis
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Ultrasonography is a simple nonradiological imaging tool, and although it may miss early myositis, deep muscle abscesses, or lesions, its beam cannot detect these sites
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However, contrast-enhanced CT and MRI allow a comprehensive assessment of muscle damage
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If clinical symptoms (including fever, local edema, swelling, and erythema) do not improve after empiric antibiotic therapy, repeat CT examinations are required to monitor disease progression and determine the timing of surgical intervention
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 In the current case, there was no abscess formation in the chest wall on the first CT scan
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However, 7 days later and subsequent CT examinations showed extensive abscess formation, and accurate assessment of the location and extent of the muscle abscess was essential for both treatment and preoperative planning
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 SUMMARY Infections such as abscess or suppurative myositis should be considered when a patient with SLE presents with unilateral limb edema in the presence of fever
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Pyomyositis may resemble deep vein thrombosis and is easily misdiagnosed in SLE patients with unilateral extremity edema
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Imaging evaluation (eg, CT) and identification of the causative pathogen are critical for the diagnosis of purulent myositis
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Early and effective antibiotic treatment and surgical intervention can provide satisfactory results
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References: [1] Yu- Ning Kuo, Chih- Sheng Lai, Yi- Hsing Chen, et al.
Severe thoracic pyomyositis in a patient with systemic lupus erythematosus[J].
BMJ Case Rep 2022;15:e246484.
doi:10.
1136 /bcr-2021-246484