Correct!
2. Disseminated intravascular coagulopathy (DIC)
DIC is a pathological imbalance in the procoagulant and anticoagulant systems, which leads to unregulated thrombin generation (1). DIC is secondary to many states, including sepsis/infection, malignancy, and trauma. DIC classically presents with a low platelet count, elevated INR, elevated PT and PTT times, as well as a decreased fibrinogen level. Peripheral smear demonstrates shistocytes, and low platelet levels that are also reflective of DIC. Microangiopathic hemolytic anemia is incorrect given it typically presents with normalized PT, and PTT times, as well as normalized fibrin levels. Thrombotic thrombocytopenia purpura and autoimmune hemolytic anemia would be unlikely given the patient’s normal bilirubin levels.
The patient was subsequently intubated and placed on norepinephrine for hypotension and piperacillin and tazobactam for presumed sepsis. Blood cultures were positive for gram-positive cocci in two out of two cultures. A lumbar puncture was performed which noted a total nucleate cell count of 1/uL, glucose of 57 mg/dL, protein 69 mg/dL, with an HSV IgG of 0.12. Lactic acid was 5.5mmol/L. Streptococcus pneumoniae antigen and urinary Legionella antigen were negative. Computed tomography (CT) scan of the brain, thorax, abdomen, and pelvis was notable for diffuse body wall edema as well as bilateral lower lobe atelectasis.
Given the patient’s medical history and clinical presentation what organism would have likely precipitated the current presentation? (Click on the correct answer to proceed to the third of five pages)