Anesth Analg 2008; 106:675-676
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e318160f885
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Uncertain Usefulness of Procalcitonin as Reliable Marker of Sepsis?
Mario Achim Klinkhammer,
Friedrich Weber,
Frank Wappler, and
Samir G. Sakka
Department of Neurosurgery; Medical-Center Cologne-Merheim; Cologne, Germany (Klinkhammer, Weber)
Department of Anesthesiology and Intensive Care Medicine; University of Witten/Herdecke; Medical Center Cologne-Merheim; Cologne, Germany; sakkas{at}kliniken-koeln.de (Wappler, Sakka)
To the Editor:
Serum procalcitonin (PCT) has been proposed as a diagnostic marker of sepsis and to differentiate between sepsis, severe sepsis, and septic shock.1–3 In addition, serial measurements of PCT have been used to guide antibiotic treatment.4 However, the value of PCT as a marker of sepsis has also been questioned5 because of a sensitivity and specificity of <80%.6
An 80-yr-old male patient was treated in a neurological rehabilitation clinic after cerebral infarction with residual right-sided hemiparesis and aphasia. After 7 wk of treatment, his neurological status deteriorated and he developed anisocoria and eye deviation. After tracheal intubation due to a comatose state, he was transferred to our hospital. His history before hospitalization for stroke was characterized by a methicillin-resistant Staph. aureus (MRSA) colonization, arterial hypertension, insulin-dependent diabetes mellitus, and intermittent atrial fibrillation.
Until 6 days before admission to our hospital, he had been treated with metronidazole for Clostridium difficile toxin positive enterocolitis. A CT scan of the head revealed no pathology other than the cerebral infarction areas and the chest radiograph was normal. On arrival, heart rate (90/min) and blood pressure (115/70 mm Hg) were within normal limits. The patient was febrile (38.0°C) with a leukocytosis (15,700/mL), PCT of 209.7 (normal <0.5 ng/mL) and increased C reactive protein (CRP) (248.8 mg/L) and serum creatinine (2.4 mg/dL). However, both serum bilirubin and the platelet count were normal. A urine analysis showed both increased leukocytes and erythrocytes and positive nitrite and levofloxacine was started for treatment of the urinary tract infection.7 Although hemodynamics were stable, he underwent a positive fluid balance of 1100 mL during the first 24 h after admission and the trachea was extubated on the following day. One day later he was returned to the rehabilitation facility. At this time PCT was 105.7 ng/mL, CRP was slightly lower (201.6 mg/L) and creatinine 2.0 mg/dL. The patient had further febrile episodes and both urine and blood cultures were positive for E. Coli and resistant to levofloxacine. He was treated with cefuroxime and recovered completely. Over the next several days, CRP decreased from 154.2 to 111.3 and finally 70.8 (normal <8.2 mg/L).
This case report raises two relevant issues: 1) increased levels of PCT in a patient who had stable hemodynamics and no multiple organ dysfunction and 2) PCT may not be a reliable marker of inflammation as antibiotics were tested to be not sensitive for the organism responsible for infection. This patient had an extremely high PCT that might be associated with septic shock and multiple organ failure, neither of which was present. Furthermore, although the antibiotic treatment was inappropriate, PCT indicated adequate therapy because it decreased by half during the first 24 h of treatment.8 Because there was no other septic focus and the microbiological results were confirmed by the other institution, the reliability of PCT as sepsis marker remains unclear. However, our patient may not have been septic on admission to the intensive care unit and may have developed altered mental status at the rehabilitation facility due to fever for urinary tract infection and not sepsis. Furthermore, the decreasing PCT (and CRP and serum creatinine) may have been caused in part by fluid resuscitation and because PCT was not obtained after transfer, we cannot exclude the possibility that our patient developed sepsis only after transfer back to the rehabilitation facility. This report suggests that interpretation of PCT values as a diagnostic marker of sepsis should be made with some caution.
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