Aortic Dissection Presenting With Septic Shock

Author : A. Satria, S. Widito
Upload Date : 19-04-2018

Background : Aortic Dissection is the separation of the aorta into two areas of blood flow. The true and false lumen held apart by an arterial flap resulting from the tear. Symptomps can vary according to where the tear is localised, and where it migrates to. In most cases this is associated with a sudden onset of severe chest or back pain.

Sepsis is defined as life thretening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular/ metabolic abnormalities. Changes in the clincal sign and several biomarkers reflect inflammation-infective condition was possibly due to bacterial translocation due to mesenteric ischaemia caused by aortic dissection. This case is rare but can serve as reminder that aortic dissection may be accompanied by septic shock that have grave outcome.

Cases : A 49 years old man presenting with chestpain accompanied with vomitting, fever, diarrhea, and oliguria. He referred to the emergency room with clinical suspicion of mediastinum tumor and superior vena cava syndrome and has been treated several days by pulmonologist. The day before, he suddenly felt a strong chest pain  (scale 8-10) at the back, lasted about 15 minutes, diaphoresis, and difficulty in taking deep breaths. He also been diagnosed as Heart failure reduced ejection fraction, stage II hypertension, and stable coronary artery disease. He already took several medication like Captopril, furosemide, Nitrate, and bisoprolol since 5 years ago.      

He looked severely ill, blood pressure was 100/ 54 mmHg, heart rate 114 bpm, RR 28 tpm, saturation 99% with oxygen 4 lpm,  axillar temperature about 38.80 C. Electrocardiogram was immediately taken which showed normal sinus rhythm, LVH, with ST depression in I, avL, and there are no ST-T dynamic changes in evaluation. Laboratory findings were as follows, Creatine Kinase (CK) 5639 IU/L, CRP 2.23mg/dL, White blood cell 16.810/ µL, procalcitonin 11.3 ng/mL, D-dimer assay 27.01 mg/L FEU, ureum/ creatinine  259.2/ 10.65 mg/dL. He suffered into Septic condition, acute kidney injury stage III, with fully compensated metabolic acydosis. The sequential organ failure assesment score in this patient was 14.

The chest radiograph showed mediastinum widening, cardiomegaly and aortic elongation. The Transthoracal echocardiography showed the dilatation of  annulus aorta, sinotubular junction, ascending aorta, and descending aorta. Therefore, The CT results showed extensive thoracoabdominal aortic dissection De Bakey type I, Stanford type A, involving brachiocephalic trunk, bilateral common carotid artery, and bilateral subclavian artery. Unfortunately, this diagnosis was missed initially and the patients relatives refused definitve  surgical procedure due to his deteriorated condition. Patient was died several hours after the diagnosed has been established.

Conclusion :   Aortic dissection is a life threatening emergency with difificult diagnosis and have a high mortality index. The prognosis of aortic dissection is grave with more than 50% mortality, due mainly to late diagnosis and inadequate treatment. Aortic dissection also has several consequences that as deadly as itself like septic shock. The diagnosis of aortic dissection requires a high index of suspicion, prompt history taking and physical examination, supported by various imaging modalities that can help to make an early diagnosis and intervention to reduce mortality. Our case can serve as a reminder that aortic dissection is a difficult case and could be a potential cause of septic shock.

KEYWORDS : Aortic dissection, Septic shock, Mesenteric ischaemia

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