Case report: short time reversible myocardial dysfunction in sepsis treated with drotrecogin alpha

Severe sepsis is a complex process that involves a number of host immune responses with an orchestration of various specific and nonspecific soluble factors and cellular elements that may result in a completely different outcome. Among organ dysfunction induced by sepsis, heart failure can occur in up to 40% of cases [1]. Myocardial depression in shock probably was first described in 1947 [2]. Its onset may be extremely early, but is most evident in the first 3 days of the disease. Normalization usually happens over the following 7-10 days in the survivor patients [3]. We have described an atypical sort time reversible myocardial dysfunction, in a patient with rapid evolution to a multiple organ dysfunction syndrome (heart, renal, pulmonary, and hematological). An 87-year-old man with hypertension and diabetes mellitus type 2 was admitted to our intensive care unit (ICU) with severe sepsis caused by community-acquired pneumonia. On the following day of his ICU entrance he developed septic shock which was associated with an increase in the cardiac enzymes, particularly troponin I and CK mass (fluorogen immunoassay). We started the infusion of Xigris^®, a recombinant version of human activated protein C, according to the PROWESS [4] protocol. His baseline examination characteristics before and 3 days after Xigris^® infusion are summarized in Table 1.

Table 1

The patient was discharged 10 days after the Xigris^® end-of-infusion to a step-down unit. The physiology of the myocardial dysfunction that occurs in systemic inflammatory response syndrome is not well understood, although there are several theories to explain it [5–8]. We are reporting an unusual behavior of reversible nonischemic myocardial dysfunction possibly related to Xigris^® treatment. Perhaps this communication could be tested in a well-designed study to address a new hypothesis for new applications of activated protein C outside the setting of severe sepsis.