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January 6, 2020

Image challenge: Septic shock after travel to rural Africa

What caused septic shock in a patient that recently consumed unpasteurized milk and well water?
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Gastroenterology clinical image challenge: A 60-year-old African woman presented to the emergency department with three days of abdominal pain, nausea and vomiting. She had recently returned from a 10-month trip through rural Ethiopia where she consumed unpasteurized milk and well water with exposure to goats, cats and livestock. Her medical history was otherwise unremarkable.

On examination she was tachycardic (110 beats per minute), hypotensive (53/34 mm Hg) and afebrile. Her examination was notable for midline abdominal tenderness. Laboratory findings were notable for white blood cell count of 22 × 109 cells/L without eosinophils, hemoglobin of 13.3 g/dL, platelet count of 35 × 109/L, total bilirubin of 1.4 mg/dL, direct bilirubin of 0.6 mg/dL, alkaline phosphatase of 143 U/L, aspartate aminotransferase of 38 U/L, alanine aminotransferase of 40 U/L and lactate of 8.3 mmol/L. Blood cultures on admission grew Klebsiella pneumoniae. A noncontrast computed tomography scan of the abdomen was notable for hepatomegaly and cavitary lesions in the left lobe of the liver consistent with abscesses, pneumobilia and gallbladder distension.

Percutaneous drainage of the gallbladder and left liver abscess was performed, with frank pus aspirated from the abscess. MRCP revealed a diffusely dilated biliary tree with tubular filling defects in the extrahepatic ducts.

What is the etiology of the patient’s septic shock?

To find out the diagnosis, read the full case in Gastroenterology.

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