A 21-year-old college student presented to a tertiary care hospital with history of on and off low-grade fever for 3 months and abdominal pain for 1 week. She had no history of cough with weight loss or facial rashes. On admission, she was conscious but anxious and pale. She had blood pressure on the lower side of normal with distended abdomen. Both tuberculosis and vasculitis like systemic lupus erythematosus (anti-dsDNA, anti-sm-RNA) were ruled out in view of low-grade fever with abdominal pain. Erect X-ray and abdomen ultrasonography were normal. On the third day of hospital admission, she developed septic shock (mean blood pressure <65 mmHg) with altered sensorium for which she was intubated and transferred to the intensive care unit (ICU). Magnetic resonance imaging of head, cerebrospinal fluid study and serum sodium level (137 mmol/L) were all within normal limits. She had leukocytosis (21,000/cmm), anemia (5 gm/dL), thrombocytopenia (20,000/cmm) and deranged liver function tests (prothrombin time 6 s prolonged). Echocardiography showed mild diastolic dysfunction with ejection fraction >60%. She was managed conservatively with fluids, sedation, noradrenaline (0.5-3 mug/kg/min), vasopressin (0.01 U/min) infusion, broad-spectrum antibiotics and platelet and packed cell transfusion. Several blood and endotracheal tube aspirate cultures were sterile. On the fifth day, repeat ultrasonography of the abdomen revealed thickened and dilated nonobstructed bowel loops with coarse hepatic echo-texture. The gastro surgeon refused active management fathoming patient's prolonged shock. Since ICU admission, she had high nasogastric aspirates with feed intolerance despite the use of prokinetics; however, she started accepting nasogastric feeds on day 6. But, after a few hours of enteral feed, she developed rapidly rising intraabdominal pressure (>18 mmHg) with sudden deterioration in hemodynamics and increasing metabolic academia and hyponatremia (serum sodium 124 mmol/L). She passed large amounts of fresh blood-mixed loose stools, which was later found to be negative for Clostridium dificile. Bedside abdominal ultrasonography suspected presence of air shadows within the hepatic portal vein. Urgent computed tomography (CT) scan abdomen revealed pneumatosis intestinalis of the small bowel with dilated bowel loops [Figure 1] and gas in portal venous system [Figure 2]. In a setting of prolonged septic shock, vasopressor support and metabolic acidosis, the clinical and radiological picture was that of mesenteric ischemia. Exploratory laparotomy, done immediately, showed multiple areas of gangrenous patches and dusky discoloration of the jejunum with air bubbles in the subserosa. The major mesenteric vessels were pulsating and there was no evidence of thrombus, atherosclerosis or visible occlusion. No bowel perforation was detected. In view of extensive distribution of gangrenous patches, the surgical team released the intrabowel pressure by surgical incisions in the wall of the jejunum so as to reduce the increasing distension.
She succumbed within 4 h of operation. Postmortem examination could not be conducted as consent was not available.