Surprising number of infections end in fatal septic shock

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http://www.chron.com/cs/CDA/story.hts/health/1284708

March 7, 2002, 10:12AM

PERSONAL HEALTH

Surprising number of infections end in fatal septic shock

By JANE E. BRODY

Copyright 2002 New York Times

Can an otherwise healthy 58-year-old man die from a bad cold? He can, and he

did.

Through an unfortunate cascade of events, starting with a missed diagnosis

of viral pneumonia, Tom , a systems analyst for Westinghouse, went

from bad to worse until every major organ system -- kidneys, liver, lungs

and finally his heart -- stopped working.

After 10 days in intensive care during which doctors struggled in vain to

get ahead of the rampaging disorder, died. Cause of death: septic

shock, the same condition responsible for the death in 1990 of the Muppeteer

Jim Henson.

's death began with a bad cold he caught while abroad on vacation.

Upon returning home, he went back to work, despite a lingering cough and

fatigue that gradually worsened and prompted a visit to the doctor.

The doctor diagnosed asthma and, without ordering a chest X-ray that could

have shown pneumonia, prescribed a steroid inhaler. When 's condition

rapidly worsened, he also prescribed prednisone, which suppresses the body's

immune response and most likely made matters worse.

In 24 hours, was very sick with streptococcal pneumonia in both

lungs, landing him in the hospital in intensive care.

Sepsis is an overwhelming bodywide response to an infection that at the

outset may seem mundane but that suddenly worsens. It is a chain of events

involving abnormal inflammation and clotting that can lead to major organ

failure and death. Septic shock results when the out-of-control response

causes the heart to fail.

More than 750,000 cases of sepsis occur annually in this country, and

215,000 of those afflicted die even with intensive medical care that

includes antibiotics, intravenous fluids, blood transfusions, kidney

dialysis, nutritional and respiratory support and sometimes surgery to

remove the source of an infection.

The incidence of sepsis has nearly doubled in the last decade and is

expected to rise to 1 million cases a year by 2010. Although older people

and those with chronic ailments like diabetes or HIV infection are most

susceptible, sepsis spares no age group, attacking children as well as

adults, healthy people as well as the chronically ill.

Despite the use of potent antibiotics and advanced resuscitative equipment

costing $17 billion a year, septic shock remains the leading cause of death

in intensive care units, killing more people each year than cancers of the

breast, colon, pancreas and prostate combined.

Until now, no agent tested in well-designed clinical trials has been able to

make a dent in the death rate from sepsis. The Food and Drug Administration

recently approved for marketing the first drug proved to reduce mortality

from severe sepsis.

In effect, sepsis is the body's runaway attempt to defend itself against an

infection. A series of inflammatory and anti-inflammatory compounds are

released that attack body tissues above and beyond the original infection.

Perhaps the most damaging effect is intravascular clotting, the formation of

clots inside blood vessels that deprives tissues of needed oxygen and can

result in organ shutdown. Damaged blood vessels start oozing fluids, the

kidneys cannot function, the lungs become stiff, and ultimately the

circulation fails and blood pressure cannot be maintained.

Compounding the many devastating effects of sepsis is that the antibiotics

administered to treat the underlying infection can sometimes unleash toxic

substances. Certain streptococcal, staphylococcal and other bacteria contain

potent toxins -- exotoxins released directly into the blood by the live

bacteria and endotoxins within the organisms.

The newly licensed drug Xigris, by Eli Lilly, acts to interrupt the downward

spiral of sepsis by stemming clotting in the blood vessels. It is approved

for adults with severe sepsis who face a high risk of death. Severe sepsis

is diagnosed when sepsis causes one or more organs to malfunction. In

clinical trials, Xigris reduced the death rate by nearly 20 percent.

The drug must be used with great care, since by interfering with the ability

of the blood to clot it can cause serious internal bleeding. Dr. Gordon R.

Bernard, a pulmonologist at Vanderbilt University School of Medicine,

directed the clinical trials of Xigris. He said that although the drug was

not a cure-all, " it reduces mortality, and it's the only drug ever shown to

do that. "

Also encouraging, Bernard said, is that the current understanding of the

biochemistry of sepsis should soon result in the development of other

specific therapies.

Let's start with prevention. Two personal habits that make sepsis more

likely are smoking and excessive use of alcohol. Also, anyone with a chronic

ailment should be aware of the possibility that sepsis can occur as the

result of any infection, although half the time pneumonia is the

precipitating cause, Bernard said.

In treating sepsis, time is crucial. Many people are reluctant to seek care

until they are so sick they have no choice. Since sepsis develops rapidly

and can cause irreversible organ damage, the sooner a suspected case is

diagnosed and treated, the better. This is especially so for people who are

elderly or who have chronic ailments.

Bernard said people need to recognize a normal response to infection. They

should be aware of when their symptoms have gone beyond being just a cold,

which should not last more than about five days and cause more than a

low-grade fever. When fever rises to 102 or 103 with shaking chills,

confusion or difficulty breathing, the patient should be taken to the

hospital without delay and receive immediate attention in the emergency

room.