A near-fatal case of hidradenitis suppurativa associated with sepsis and ischaemic heart disease

A 38-year-old man who was a heavy smoker was diagnosed with hidradenitis suppurativa 7 years ago after he developed chronic, painful nodules, abscesses, suppurating sinus tracts and comedones with substantial scarring on his skin (Figure 1). He was prescribed topical clindamycin, apremilast 30 mg twice a day, and several courses of corticosteroids. The patient did not undergo any investigations for cardiovascular disease or associated risk factors. A year later, the patient developed back pain. Ankylosing spondylitis was diagnosed based on seronegative haematology and a pelvic X-ray showing sacroiliitis. He was offered analgesia and physiotherapy. Six years later, the patient presented to the emergency department with cellulitis on his back secondary to the hidradenitis suppurativa lesions, fever, tachycardia and confusion. Sepsis was confirmed after blood cultures grew meticillin-resistant Staphylococcus aureus. Haematological and biochemical investigations revealed leucocytosis, anaemia, impaired renal function, ischaemic hepatitis and rhabdomyolysis. He developed pneumonia as diagnosed on a chest X-ray, and sputum cultures grew meticillin-resistant Staph. aureus. The patient was treated in the intensive care unit. Refractory respiratory failure necessitated intubation and mechanical ventilation. He recovered after 8 days and was transferred to internal medicine. The patient described experiencing dyspnoea and leg oedema for the previous 6 months. Transthoracic echocardiography showed a globally hypokinetic left ventricle with an ejection fraction of 30%, and he was also diagnosed with hypertension. The patient was commenced on ramipril 2.5 mg once a day, metoprolol 100 mg twice a day, spironolactone 25 mg once a day and furosemide 40 mg as needed. A resting electrocardiogram revealed inverted T-waves in the lateral leads. Cardiac troponin levels were consistently negative. Invasive coronary angiography revealed high-grade lesions in the proximal segments of the left anterior descending artery, ramus medianus branch, right posterior descending artery, and a chronic total occlusion of the first obtuse marginal branch (Figure 2). The patient chose percutaneous coronary intervention rather than surgical revascularisation. His lipid panel, haemoglobin A1c level, and ultrasound of the carotid arteries were normal. A month later, while awaiting percutaneous coronary intervention, the patient experienced another episode of septic shock secondary to a urinary tract infection. Cultures grew Klebsiella pneumoniae. He was treated and made an uneventful recovery. A month after this, he underwent four successful percutaneous coronary interventions with drugeluting stents. Pre-discharge transthoracic echocardiography revealed a left ventricular ejection fraction of 45%. The patient was prescribed aspirin 75 mg once a day, clopidogrel 75 mg once a day, atorvastatin 20 mg once a day and ivabradine 7.5 mg twice a day. The rheumatologist switched apremilast to adalimumab 80 mg every 2 weeks. The patient will require lifelong follow up. © 2024 MA Healthcare Ltd.