A Curious Case of “Septic Shock”

• Published in: The Journal of emergency medicine 2017-03, Vol.52 (3), p.e61-e63
• Main Authors: Lakshman, Arjun, MD, MRCP, Singh, Charanpreet, MBBS, Singhal, Manphool, MD, Jain, Sanjay, MD, DM, Sharma, Navneet, MD, Kumari, Savita, MD, DM, Varma, Subhash, MD
• Format: Article
• Language: English
• Subjects: Adult; Anti-Bacterial Agents - pharmacology; Anti-Bacterial Agents - therapeutic use; Antimalarials - pharmacology; Antimalarials - therapeutic use; Artemisinins - pharmacology; Artemisinins - therapeutic use; Ceftriaxone - pharmacology; Ceftriaxone - therapeutic use; Drug Combinations; Emergency; Female; Humans; Malaria, Vivax - complications; Malaria, Vivax - physiopathology; Norepinephrine - pharmacology; Norepinephrine - therapeutic use; Plasmodium vivax - pathogenicity; Primaquine - pharmacology; Primaquine - therapeutic use; pseudohypotension; pulseless disease; Pyrimethamine - pharmacology; Pyrimethamine - therapeutic use; Shock, Septic - etiology; Shock, Septic - physiopathology; Sulfadoxine - pharmacology; Sulfadoxine - therapeutic use; Takayasu arteritis; Takayasu Arteritis - complications; Takayasu Arteritis - physiopathology; upper limb occlusive arterial disease; Vasoconstrictor Agents - pharmacology; Vasoconstrictor Agents - therapeutic use; Vasopressins - pharmacology; Vasopressins - therapeutic use
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2016.10.014

Abstract Background Takayasu arteritis, also known as “pulseless disease,” causes proximal occlusion of the lumen of large arteries of the neck and arm, leading to impalpable pulses and “pseudohypotension.” This may misdirect the management plan for a patient in the emergency setting if the presence of vascular occlusion is not previously known. Case Report We describe a young woman who presented to the emergency department (ED) with fever. On evaluation, she had shock, which was not responsive to a fluid bolus. Bedside Rapid Diagnostic Test was positive for Plasmodium vivax , and a diagnosis of severe vivax malaria was made. She was started on intravenous artesunate and vasopressors in view of her persistent hypotension in the face of a normal central venous pressure. A thorough examination at that time revealed palpable lower limb pulses with feeble upper limb pulses. Vasopressors were tapered while monitoring lower limb blood pressure. Computed tomographic angiogram confirmed the diagnosis of Takayasu arteritis. Why Should an Emergency Physician Be Aware of This? Hypotension and shock are regularly encountered in the ED. Occlusive arterial disease involving upper limbs can mimic refractory shock, leading to potentially harmful and unnecessary interventions. Emergency physicians should be aware of this possibility. A simple routine of quickly checking all peripheral pulses would help them avoid this pitfall.