A 51-year-old woman with a one-month history of redness and swollen left knee joint was transferred to our general intensive care unit (ICU) due to persistent high fever (up to 39.5 C) and sudden hypotension. After being diagnosed with dermatomyositis 2 years ago, she continued medication treatment on prednisone tablets with a 25 mg daily dose and cyclosporine capsule with a 75 mg dose twice per day. Last month, the results of blood culture and bacterial culture of joint cavity pus as obtained from other medical institutions were shown to be negative, with no special microbiological examination performed.
When the patient visited the rheumatology department for appointment with a doctor, she coughed up sputum intermittently and her body temperature reached up to 40 C. Physical examination revealed that the left knee was red and swollen with positive floating patellar test, along with red rash in the V area of face and neck. The right dark yellow pleural effusion displayed exudate and negative bacterial culture. Vancomycin was thus prescribed to reduce infection, and 20 mg of methylprednisolone was applied twice a day. Four days later, she was transferred to ICU due to hypotension (the detailed clinical course is shown in Figure 1). The patient exhibited low blood pressure and high heart rate, which was accompanied by elevated procalcitonin and multiple organ failure. Broad-spectrum anti-infective therapy (imipenem/cilastatin + linezolid) was initiated within the first hour of highly suspected septic shock. ECG suggested cardiac infarction and high myocardial enzyme index. In order to rule out the occurrence of acute cardiovascular event, no infarction was detected immediately after coronary angiography. Given the EF value of 30% for the patient, septic heart disease was suspected. At the same time, the patient suffered acute liver injury, acute renal injury and thrombocytopenia.
After the patient was transferred to ICU, joint cavity pus was also taken for culture in addition to blood culture samples (ultrasound: Figures 2A,B, MRI: Figures 2C,D). Considering that the patient had negative culture multiple times in the previous month, the NGS examination was conducted for joint cavity pus and blood samples at the same time. Subsequently, NGS results indicated that the pathogen was "M. tuberculosis," with acid-fast bacilli unexpectedly visible in articular cavity effusion. After an inquiry made about her medical history, it was known that the patient had a history of contact with pulmonary tuberculosis, and such symptoms as night sweating, coughing and expectoration were manifested since around the last month. Thus, the septic shock associated with M. tuberculosis was suspected. Five combinations of anti-tuberculosis drugs (HRZEO: Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, Ofloxacin) were prescribed, while imipenem/cilastatin was downgraded to piperacillin/tazobactam and vitamin B6 was prescribed as a supplement. The bronchoalveolar lavage fluid was found negative for acid-fast staining. The T-SPOT results of the patients remained negative. The T lymphocyte count of the patient was shown to be extremely low. After about 10 days of anti-tuberculosis treatment, the body temperature improved, the ST segment of ECG decreased, myocardial enzymes returned to normal, shock was alleviated, and the count of platelets increased. Unfortunately, liver function deteriorated for the patient gradually. Five days after the adjustment made to anti-tuberculosis drugs, the patients showed such tuberculosis poisoning symptoms as high fever and shock, norepinephrine of 1.2 ug/kg/kg min, which was accompanied by a decline in the count of platelet again. Afterwards, both liver function and cardiac function further deteriorated. Re-examination of blood NGS remained suggestive of M. tuberculosis. Our advice against further treatment was rejected by her family members.