This report details the clinical journey of a 48-year-old woman with a history of diabetes mellitus, hypertension, and polycystic ovarian syndrome (PCOS). The patient was referred from a peripheral hospital to the tertiary care BIRDEM General Hospital in Dhaka, Bangladesh, presenting with a complex clinical picture that included sepsis, acute kidney injury (AKI), and deep jaundice. The case underscores the challenges of managing multi-organ dysfunction in a patient with significant metabolic and endocrine comorbidities.¹

Case Presentation

• The patient was admitted in a peripheral hospital on January 4^th, 2024, with the history of fever, yellowish discoloration of skin, sclera and urine associated with intense itching for 7 days.
• She gave a history of taking NSAIDs and herbal medication for her illness.
• She gradually developed reduced urine output.
• She had leukocytosis – 44.80 K/μl, hyperbilirubinemia-15.2 mg/dl, altered liver enzymes along with an ESR of 41 mm/hour. Her SGPT was 450 U/l and ALP (Alkaline Phosphatase) was 902 U/l. Intravenous antibiotic ceftriaxone was started.
• Gradually her serum creatinine raised to 7.1 mg/dl which led to her receiving the 1^st hemodialysis on  January 6^th.
• Due to complexity of clinical picture, she was referred to an advanced medical center and was admitted in Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) general hospital, Shahbagh, Dhaka, Bangladesh on January 8^th.
• The patient was conscious, oriented, breathing spontaneously (O2 via nasal cannula) but was slightly somnolent. On examination bilateral crepitation was observed.
• After a short duration the patient developed respiratory distress and therefore shifted to ICU.
• Her serum bilirubin raised to 24.1 mg/dl, procalcitonin was 23.2 μg/l, serum creatinine 9.7 mg/dl, ferritin 2268 ng/ml and serum potassium 6.3 mEq/L.²
• Her chest X-ray showed bilateral pulmonary edema.
• All serological markers for hepatitis were negative.
• Her antinuclear antibody (ANA) test was positive.
• Along with standard of care, on January 9^th she received a 2^nd hemodialysis in association     with CytoSorb^®.
• The 3^rd hemodialysis along with CytoSorb^® was given after the passing of 24 hours of the previous one.
• Her overall condition and lab parameters improved.
• The patient was shifted to ward on January 13^th and after a complication free course she was sent to home on January 26^th.

Treatment

• Two sessions of CytoSorb^® was completed over a period of 48 hours duration. Each session consisted of 12 hours duration with 24-hour interval between the sessions.
• CytoSorb^® was used in combination with renal replacement therapy by Dialog+^® of B. Braun Medical Inc.
• Blood flow rate: 150 ml/min.
• Dialysate flow: 2000 ml/min.
• Anticoagulation: None.
• CytoSorb adsorber position: pre-hemofilter.
• Antibiotic therapy with meropenem and moxifloxacin were started.

Measurements

• Excretory liver function (bilirubin)
• Liver enzymes (SGPT, SGOT)
• Inflammatory marker (PCT)
• Level of consciousness

Results

• After the two CytoSorb^® sessions, bilirubin plasma concentrations significantly decreased to 5.6 mg/dl from 24.1 mg/dl. The serum bilirubin level remained stable at this level and later dropped spontaneously over the subsequent days.
• Liver enzymes also decreased after CytoSorb^® sessions. SGPT decreased to 59 U/l from 335 U/l and SGOT decreased to 92 U/l from 183 U/l.
• PCT (Serum procalcitonin) also decreased from 23.2 μg/l to 9.54 μg/l.
• The patient was breathing spontaneously and was oriented.

Patient Follow-Up

• The subsequent days at intensive care was characterized by an oriented and cooperative patient who was hemodynamically stable.
• After 5 days of ICU stay, she was transferred to the normal ward.
• The patient was discharged from the hospital on January 26^th after 13 days of complication free period.

Conclusions

• In this patient with sepsis, AKI and acute fulminant hepatitis, the combined treatment with standard therapy, renal replacement therapy and CytoSorb^® resulted in the rapid reduction  of plasma bilirubin concentrations and stabilization of inflammatory markers.
• CytoSorb^® was preferred due to its ease of use combined with high efficiency and proven safety profile.
• CytoSorb^® was safe and easy to use in combination with the RRT (Renal Replacement Therapy).

Authors of this article

1. Dr. Mohammad Golam Azam, MD, Associate Professor, Department of Gastrointestinal, Hepatobiliary and Pancreatic Disorders (GHPD), drgolamazam@gmail.com
2. Prof. Dr. A.S.M. Areef Ahsan, FCPS, MD, Professor, Head, Department of critical care medicine
3. Dr. Mehruba Alam Ananna, FCPS, Associate professor, Department of nephrology and dialysis
4. Dr. Israt Jahan, FCPS, Registrar, Department of critical care medicine.

Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) general hospital, Shahbagh, Dhaka, Bangladesh.

Reference

1. Communications E. Rehabilitation of Right Hemisphere Disorder in the Chronic Phase of Recovery. Accessed February 10, 2025. https://medonecomsci.thieme.com/cockpits/cllogopedics/0/coCPeComCa0271/0

2.  Manzanares W, Cancela M, Berrutti D. Shock and Pulmonary Edema Secondary to Severe Acute Hypercapnic Acidosis. Am J Respir Crit Care Med. 2010;182(11):1455-1455. doi:10.1164/ajrccm.182.11.1455