A woman in her fifties with a post-operative infection, generalised rash and organ failure

A woman in her fifties was urgently admitted to the surgical department of her local hospital due to fever, reduced general condition and dyspnoea five days after day surgery for right-sided breast cancer including breast-conserving surgery and sentinel lymph node biopsy.

The woman had an existing diagnosis of type 1 diabetes mellitus, hypertension, migraine, COPD and fibromyalgia. She smoked fewer than 10 cigarettes daily. Her regular medications consisted of insulin pump therapy, enalapril 20 mg perorally, and acetylsalicylic acid 75 mg perorally.

Upon admission, the woman was awake and alert. She had a body temperature of 38.6°C, respiratory rate of 20/min, oxygen saturation of 97 %, pulse of 95/min and blood pressure of 133/56 mmHg, as well as slight redness and discharge from the surgical wound on her breast.

Blood tests showed CRP 332 mg/L (reference range < 5), leukocytes 10.1 ∙ 10⁹/L (3.5–8.8), including neutrophil granulocytes 9.6 ∙ 10⁹/L (1.5–7.3), creatinine 101 μmol/L (45–90) and eGFR 53 ml/min/1.7m2 (≥ 60). Arterial blood gas was pH 7.41 (7.35–7.45), pCO2 4.2 kPa (4.64–6.40), pO2 8.6 kPa (11.1–14.4) and lactate 1.1 mmol/L (0.7–1.6).

The woman did not meet any of the quick Sequential Organ Failure Assessment Score (qSOFA) criteria, but she met three of the four criteria for systemic inflammatory response syndrome (SIRS) and showed signs of organ dysfunction, with dyspnoea and reduced renal function. Incipient sepsis was therefore suspected. Blood cultures, a urine sample and nasopharyngeal PCR were taken, and sepsis treatment was initiated with intravenous cloxacillin 2 g × 4 and gentamicin 420 mg × 1.

As there was no breast and endocrine surgeon at the hospital, the patient was transferred the same day to the university hospital where she had undergone the procedure. Here it was found that she had developed a pruritic, diffuse, symmetrical erythema on the thorax and extremities. An allergic drug reaction to antibiotics was suspected, and a switch was made to intravenous clindamycin 600 mg × 4 monotherapy, and desloratadine antihistamines 5 mg × 2 perorally were initiated.

The day after the transfer, the patient's condition worsened. NEWS (National Early Warning Score), a scoring system for assessing vital functions, increased from 2 to 9. She was awake but not fully alert. Despite infusion of a total of 1 L Ringer's acetate and 2 L NaCl 9 mg/ml, as well as 250 ml NaCl of intravenous fluid, her blood pressure was 88/54 mmHg. Pulse was 99/min, respiratory rate 26/min, oxygen saturation 95 % in room air and body temperature 38.4°C. She was anuric, and blood tests showed acute renal failure with creatinine 258 μmol/L (45 - 90), eGFR 17 ml/min/1.7m2 (≥ 60) and carbamide 15 mmol/L (2.6–6.4). Electrolyte tests showed moderate hyponatraemia 128 mmol/L (137–145) and normal potassium 4.2 mmol/L (3.6–5.0). Arterial blood gas showed compensated metabolic acidosis with pCO2 3.9 kPa (4.64–6.40), lactate 4 mmol/L (0.7–1.6) and base excess - 4 (-3–3). Elevated CRP and leukocyte count were unchanged. She reported no muscle pain and creatine kinase was normal.

The woman was transferred to the ICU for vasopressor therapy. Here her respiration was stable and she was breathing spontaneously without the need for oxygen. She maintained mean arterial pressure > 65 mmHg with the highest dose of intravenous noradrenaline of 0.08 µg/kg/min. She received a Ringer's acetate infusion and had a sparse but increasing hourly urine output of 30 ml/h. Glucocorticoids were unnecessary as she responded rapidly and stabilised on vasopressors and fluids. A serious streptococcal or staphylococcal infection was suspected, and the antibiotic therapy was supplemented with infusion of cefotaxime 2 g × 3 (in addition to the already initiated clindamycin).

The woman also had diarrhoea, with 3–4 loose bowel movements per day. She was tested for COVID-19 and influenza, as well as Clostridium difficile, but all tests were negative. Liver function tests showed mild abnormalities, with ALAT 70 U/L (10–45), ASAT 60 U/L (15–35), GT 195 U/L (10–75) and ALP 330 U/L (35–105). Total bilirubin was normal at 17 µmol/L (< 26). No petechiae or ecchymoses were observed on the skin, and coagulation tests showed an INR of 1.2 (0.8–1.2), with platelets within the normal reference range. D-dimer was elevated, at 4.7 mg/L (< 0.5), aPTT was 62 seconds (22–30) and fibrinogen 6.4 g/L (1.7–4.2).

The patient experienced increasing shortness of breath after transferral to the ICU. Chest x-ray revealed congestion and small amounts of bilateral pleural effusion. She also developed pitting oedema in all four extremities, and blood tests showed a proBNP level of 13,505 ng/L (≤ 287). Results of blood cultures taken on the first, second and fourth days of hospitalisation were available after five days and were negative. ECG showed supraventricular tachycardia with a normal axis, with no signs of ischemia or bundle branch block. Echocardiography showed good biventricular function with an ejection fraction of 58 %. No vegetations on the valves or other evidence of endocarditis were detected. Left atrium was enlarged, 51 ml/m2, right atrium was not enlarged, 30 ml/m2, and the patient had mild tricuspid regurgitation. Tricuspid gradient was measured at 2.7 m/s (< 2.8). It was concluded that the patient had diastolic dysfunction grade 2. She received diuretic treatment with furosemide 20 mg × 2 perorally, which showed good clinical efficacy.

The day after transferral, we also observed that the rash had spread to the whole body, and the skin on the palms of the hands and soles of the feet were starting to peel (Figure 1). The patient's medical history and clinical presentation led us to consider toxic shock syndrome. Despite only mild redness around the surgical wound on the breast, the breast surgeon decided to open and revise the wound under local anaesthesia in the ICU. There was no visible pus or fluid accumulation in the wound, and the tissue appeared healthy. Samples were taken from the wound for cultures, and the skin was only partially closed to allow any potential fluid to drain out.

After two days in the ICU, the patient's respiration and circulation were stable, and she was transferred to the ward. Due to a persistent body temperature above 38°C, symptoms of organ failure such as dyspnoea, renal failure and heart failure, as well as persistently elevated CRP (200 mg/L) and leukocytes (21 ∙ 10⁹/L) for more than four days, re-surgery under general anaesthesia was decided on. A quadrantectomy was performed of the entire lower medial quadrant of the right breast, corresponding to the affected area, and more samples were taken for cultures.

After re-surgery, the patient's general condition improved significantly, the rash faded and the skin on the palms of the hands and feet peeled off. Renal function returned to normal after ten days. Infection markers gradually decreased: on the ninth day, CRP was 69 mg/L and leukocytes were 17.5 ∙ 10⁹/L. Cultures from the surgical wound were available on the fifth day and showed a pure culture of Staphylococcus aureus. Antibiotics were changed to peroral dicloxacillin 1 g × 4, based on susceptibility testing results. The patient was discharged after 15 days of dicloxacillin (total duration of antibiotic therapy of 22 days) and tapering doses of furosemide.

At the outpatient check-up three weeks later, proBNP was 740 ng/L (≤ 287), and infection parameters, renal function and liver function were normal. The wound on the breast appeared innocuous, and secondary closing was performed under local anaesthesia in the outpatient clinic.