FIRST REPORT OF DISSEMINATED INTRAVASCULAR COAGULATION CAUSED BY ACTINOBACILLUS UREAE INFECTION IN BRAZIL

Actinobacillus ureae is a commensal bacteria of the respiratory tract, occasionally implicated in severe infections. Here, we present the first case of A. ureae infection presenting as Disseminated Intravascular Coagulation (DIC). This is also the first report of A. ureae infection in Brazil. An immunocompetent 62 year-old woman was brought to the Emergency Department because of an altered level of consciousness. Family members reported that the patient had been well until the previous day, when she presented vomiting and back pain. At hospital arrival, the patient was unarousable, with a circulatory shock and showed diffuse petechiae and ecchymosis. Attempts to obtain a venous access resulted in prolonged bleeding. Intensive support with intubation, vasoactive drugs and broad spectrum antibiotics were initiated for suspected septic shock. An initial laboratory work-up revealed granulocyte left shift to myelocytes and severe thrombocytopenia (platelets 15.000 μL), triggering the hematological consultation. Further laboratory evaluation showed prolonged coagulation times, low fibrinogen (166 mg/dL) and high D-dimer (104.602 ng/mL), confirming the diagnosis of DIC (ISTH DIC score = 6-points). Blood smear showed intense vacuolization of the myeloid series. Tomography scans showed no CNS or other critical organ bleeding, neither skull fracture. Unfortunately, the patient evolved with refractory shock and passed away within a few hours of hospital admission. Results from blood cultures showed rapid growth (5 hours) of A. ureae in both aerobic and anaerobic samples. Autopsy revealed a purulent meningitis as the cause of death of the patient. A. ureae is a rare cause of severe infection, with only 38 cases described in the literature. Meningitis comprises 40% of these cases, usually related to alcohol intake or immunosuppression and head trauma or neurosurgical procedures. The current case stands out as the patient had no known immunosuppression or recent surgery. Moreover, in spite of previous reports of meningitis and sepsis due to A. ureae infection, this is the first case to report the occurrence of DIC in this condition. The finding of DIC highlights the severity of the infection, which led to the patient's death despite prompt and intensive medical care.