SEPSIS ON THE GO.

Will you be careless about a lacerated sports injury or an unknown bite on your leg? Have you ever neglected a skin abrasion by a metal piece or thorn? Do insect bites need attention? Here is the story of a young labourer, a worker from a farm, who succumbed to death following sepsis due to an unattended injury/bite on his leg about which he was totally unaware.
This man was complaining of pain on his left hip and leg for two days.The left thigh appeared swollen with mild bluish discolouration on the anterolateral aspect.. He had no past history of any systemic illness and was in good health while joining the farm. Since 1 day he had low grade fever and there was progre ssive increase in difficulty of breathing. Examination showed tachypnea, dyspnea, Pulse: 122/mt, BP: 88/64 mm Hg, SPO2: 78% on room air, Pallor +, ABG: mild metabolic acidosis, Chest: b/l crepitations,CVS: tachycardia, CNS: alert and conscious, ABD: mild splenomegaly and abdominal wall edema, Swollen, warm and tender left leg with knee effusion and normal dorsalis pedis pulsation.A definite or identifiable mark of injury was not observed on the limb. A provisional diagnosis of cellulitis with septicemia or DVT with pulmonary embolism, was made. Patient was shifted to ICU for close observation of vitals and cardiorespiratory support. IV fluids started and  oxygen by mask applied, dopamine 10-15 mic/kg/mt and dobutamine 5-10 mic/kg/mt were on flow. Blood investigations were ordered.Fluid aspirated from thigh and knee was serosanguinous in nature and awaited culture reports. Empirical broad spectrum antibiotics were started.Doppler ultrasound ruled out DVT or limb ischemia due to thrombus.X ray of left femur was normal.ECG showed sinus tachycardia, and CXR was normal. CT chest, abdomen and limb were considered but deferred as contrast could not be given due to derranged RFT, hypotension and abnormal coagulation profile. The echo cardiogram revealed Dilated left ventricle and impaired systolic function with EF 40%, and global hypokinesia, consistent with myocarditis.Fresh blood transfusion and FFP commenced. The blood investigations now showed

Hb 12.9 gm/dl, Platelet 100 K/UL, Derranged coagulation, RBS 120 mg/dl,CRP ++, ESR 70mm/hr, WBC 16K/uL, Uric acid 417 micmol/Lt.,LDH 820 u/l, CK 9495u/l, Liver function  elevated bilirubin total and direct with high ALP and AST . RFT : creatinine 200 mic mol/ltr, Hypoalbuminemia, FDP 80 mic gram/ml, Urine Hemoglobin +++ and myoglobin + peripheral smear --> WBC more than 17% bands with toxic changes along with 10% atypical lymphocytes, Microcytic Hypochomic Anemia and Megakaryocytes