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.

Characteristic	Admission	Pre-Xigris® infusion	3 days after end-infusion
Troponin I (ng/ml) < 0.4	1.1	1.6	Normal
CPK MB mass (ng/ml) < 5	6.2	9.5	Normal
C-reactive protein (mg/dl) < 1	36.3	38.7	3.6
Antithrombin (%)	64	54	89
Protein C (%)	62	48	100
D-dimer (mg/ml) < 0.5	2.15	2.34	3.28
Thrombocytes	98.000	81.000	233.000
B-type natriuretic peptide (pg/ml)	> 1300		1170
Vasopressor therapy	+/++++	++++/++++	None
Mechanical ventilation	None	++++/++++	Weaning
Echo dysfunction	+/++++	++++/++++	+/++++