Journal of Clinical Cases

Refractory Septic Shock In Pancytopenia Patient After Azathioprine Induction: A Possible Cause Of Death Of Young Female Crohn Patient: A Case Report.

Dr.Abdu Bedru (Bsc, MD, MPHE)^*, Dr.Selamawit Tilahun, MD, Dr.Sisay Gizaw, MD, Dr.Henock Fisseha, MD, Dr.Temare Birhanu,MD.

Dr.Abdu Bedru, Bsc, MD, MPHE, Manager Takaful customer experience hub. Nyala Insurance S.C. Gondar university. Addis Ababa, Ethiopia,
Dr. Selamawit Tilahun MD, Consultant internist and pulmonologist,
Dr.Sisay Gizaw MD, consultant Internist ,neurologist and physiatrist,
Dr. Henock Fisseha MD, consultant Internist , Gastroenterologist ,
Dr. Temare Birhanu MD, Consultant Internist,

Corresponding Author: Dr.Abdu Bedru (Bsc, MD, MPHE),

ABSTRACT

A 23- year- old female crohn patient was empirically induced with Azathioprine 100mg and prednisolone by mouth. Her complete blood count and liver functions were normal at the treatment initiation. However her condition progressively deteriorates despites taking the drug for a month. Hence she was admitted to medical Intensive Care unit for the diagnosis of Pancytopenia with neutropenic fever and septic shock secondary to possibly Azathioprine toxicity and subsequent sepsis. Azathioprine discontinued and pancytopenia package of management (intravenous antibiotics, vasopressors, and blood products transfusion) initiated. From fifth to ninth day of admission, she was progressively deteriorating despite adding Filgrastim and Hydrocortisone to her prior management. She was diagnosed to have Para spinal myoclonus seizure due to dyseletrolytemia on her 11th day of admission. She was relatively improving and antibiotics discontinued at 16th day of admission. On 18th day of admission, she deteriorated due to fulminant Clostridioides Difficile and or Cytomegalovirus associated Toxic mega colon. On 21st day of admission, her mentation dropped and intubated here after. Moreover Refractory septic shock and Disseminated Tuberculosis were considered. Intravenous antibiotics including antiviral and antifungal reinitiated with Anti Tb drugs at this time. On 25th day of admission, she developed cardiac arrest. Full cycles of CPR done but she could not be salvaged despite the immense efforts. The immediate cause was multi-organ failure secondary to refractory septic shock possibly due Azathioprine and subsequent sepsis induced pancytopenia. IBD as a disease of western countries now is an obsolete view. Considering the progressive increase in crohn disease, a caring physician must address the multimodal crisis from such disease with vigilance. Azathioprine if given empirically should be in low dose with gradual escalation to prevent subsequent myelosupression (5). This case also revealed the need of early empiric initiation of anti Tb in high risk patient in whom Tb and IBD cannot be differentiated. It is paramount important to consider early surgical intervention in patient with high risk colectomy like ours. More over when a patient develop refractory septic shock with neutropenic fever, it is also wise consider Tuberculosis septic shock and mange accordingly while addressing viral and fungal infection.