(1480) Septic Shock From MRSA Cholecystitis With Spontaneous Subarachnoid Hemorrhage: The Platelet Enigma

Introduction: Staphylococcal infections of the biliary tree are rare. Biliary Methicillin-resistant Staphylococcus aureus (MRSA) infections often progress to bacteremia and severe sepsis with a high mortality rate. Here, we present a case of fatal MRSA bacteremia from a biliary source causing severe thrombocytopenia and a spontaneous subarachnoid hemorrhage.

Description: A 73-year-old female with no reported past medical history presented to the emergency department (ED) with left gaze deviation, dysarthria, and altered mentation. CT scan of the brain was notable for a small right-frontal subarachnoid hemorrhage (SAH). In the ED, she developed seizure-like activity requiring intubation for airway protection. Labs revealed severe thrombocytopenia (1x10^3/mcL) and transaminitis with a cholestatic pattern. No schistocytes were seen on peripheral smear, and the coagulation profile was unremarkable. Blood cultures on hospital day 1 (HD1) were positive for gram-positive cocci, later confirmed as MRSA. MICU course was complicated by profound multi-pressor shock, oliguria, and persistent encephalopathy. Abdominal ultrasound demonstrated moderate pericholecystic fluid with anterior wall thickening consistent with acute cholecystitis. Echocardiogram revealed a mobile thrombus versus vegetation in the pulmonary artery. An emergent percutaneous cholecystostomy was performed. Purulent drainage was noted, and MRSA was isolated on culture. She deteriorated despite aggressive care with source control, and she expired on HD3.

Discussion: MRSA cholecystitis with bacteremia is associated with a 50% mortality, and rapid recognition is needed to prevent death. Emergent source control through biliary decompression is required, although is performed less frequently than other bacterial causes. Thrombocytopenia is often seen in MRSA bacteremia and is an ominous prognostic sign, particularly when severe ( < 50 x10^3/mcL). In this case, the thrombocytopenia likely led to a spontaneous SAH and the presenting symptoms. Widespread microthrombi formation in combination with septic shock led to multiorgan failure. While rare, cholecystitis should remain on the differential while investigating MRSA bacteremia in critically ill patients.