Procalcitonin as an early marker of sepsis

A 64-year-old male with an APC resistance (factor V mutation Leiden) and interrupted oral anticoagulation due to an erosive gastritis, was admitted to hospital for increasing dyspnoea. Transthoracic echocardiography revealed a floating thrombus via an open foramen ovale in both atria reaching both ventricles. Sonography showed multiple stage thrombosis of the left leg reaching to the V. femoralis superficialis. A few months previously, peripheral pulmonary artery embolization has been confirmed by scintigraphy. The patient was transferred to our hospital and underwent emergency surgery for closure of the atrial septum defect and thrombus removal. On the 4th postoperative day, the patient was transferred to the normal ward, however, on the 10th postoperative day, the patient developed a symptomatic transitory psychotic syndrome and became hypotensive before he was transferred to the ICU. Due to impaired oxygenation and the patient's history, a new pulmonary artery embolization was suspected. After ICU admission, the patient required increasing norepinephrine support and rapidly developed septic fever. However, serum procalcitonin was elevated and a computed tomography (skull, chest and abdomen) was performed for a focus search. Pulmonary artery embolism could be ruled out but an oval structure near to the ampulla recti (ca. 30x20 mm) was identified as an abscess and immediate abscess incision was performed. After surgery, the further course was characterized by a steep fall in vasopressor support and body temperature. The patient was transferred to the normal ward on the 2nd postoperative day. This case shows that procalcitonin allows early and reliable diagnosis of sepsis in patients with undefined shock.