Introduction: Septic shock is a common phenomenon seen in the intensive care unit (ICU). However, unspecified neuromuscular weaknesses and coagulopathies are not generally the initial presentations of septic shock. Our case demonstrates the interesting diagnosis and management of a patient with extended-spectrum beta-lactamase (ESBL) Escherichia coli (E. coli) bacteremia leading to septic shock. Description: A 65 year old male initially presented with lower extremity weakness. His previous history is significant for a prolonged treatment of Actinotignum schaalii osteomyelitis with ceftaroline and amoxicillin. On presentation, this patient was noted to be hypotensive and encephalopathic. He was noted to have ptosis of his left eye and diminished reflexes. Labs were most notable for an elevated international normalized ratio (INR) greater than 9. Our patient was initially managed with fluids, antibiotics, and multiple units of fresh frozen plasma (FFP). Due to no improvement in blood pressure, he was ultimately started on vasopressors. Our patient was started on intravenous immunoglobulin (IVIG) for presumed myasthenia gravis. Further coagulopathy labs were negative for disseminated intravascular coagulation (DIC), however he was empirically started on Vitamin K. Antibiotics were tailored for a two week course of ertapenem after blood cultures were positive for ESBL E. coli. Antibody testing later resulted negative for myasthenia gravis. This patient’s course was complicated by episodes of atrial fibrillation with rapid ventricular response, a septic left knee joint that was irrigated and debrided, oliguria, and transaminitis from IVIG. After several days, our patient’s course dramatically improved and he regained hemodynamic stability and organ function. Discussion: Although septic shock is commonly treated in the intensive care unit, our case represents unusual presenting symptoms. Decisions to start IVIG and Vitamin K were important points in this patient’s course, and treatment led to significant improvement with some side effects. Our case demonstrates how sepsis induced myopathy can mimic myasthenia gravis, and how ceftaroline and amoxicillin are uncommon antibiotics that can lead to Vitamin K deficiency.
Thottassery et al. (Sun,) studied this question.