Monday Pharmaceutical Mystery: What is Causing a Healthy Person to Suddenly Fall Seriously Ill?

LL is a male, age 21 years, who comes into the pharmacy to have a prescription filled for amoxicillin 500mg qid. #40. He says he will wait while you fill the prescription because he needs to get started on it right away. You notice he has never had a prescription filled before at your pharmacy. You ask him if this is the first time getting a prescription filled and he says, “yes.” He gives you all his pertinent information and states that he doesn’t have any pre-existing conditions; and that he is a body builder.

As you fill the prescription, LL asks if he can use the blood pressure machine. You hand him a bottle of alcohol and ask him to wipe it down before and after use due to the coronavirus disease 2019 (COVID-19). LL takes his blood pressure multiple times while you fill his order.

When you call LL to the cash register, he is slow to get up, and his skin is pale, with drops of perspiration. You ask him how he is doing and he says he is not doing well. He says he has been at the doctor’s office all day, and he has an upper respiratory infection. He was feeling okay up until about an hour ago. Now he feels exhausted, weak, and his blood pressure is lower than usual. It’s normally 128/78, and now it is 98/60.

You immediately recognize the danger signs and struggle to find a gentle way to tell him to go to the emergency department (ED). He should call for a ride as soon as possible.

Mystery: Why is it so urgent that this young, normally healthy person go to the ED?

Solution: LL is developing signs of sepsis. Sepsis is where there is a cytokine storm in the blood that is affecting the blood pressure and causing other systemic symptoms such as pale, clammy skin.

I see sepsis similar to a deadly food or drug allergy that quickly triggers a release of histamine, cytokines, and tumor necrosis factors. But instead, with sepsis, bacteria are the slow trigger. If caught early enough, treatment is simply antibiotics and fluids. But if it progresses too far, the condition requires pressor drugs (epinephrine-like drugs), just like food allergies require an administration of epinephrine. Both conditions are serious and potentially fatal.

When there is a large amount of cytokines in blood stream, vascular permeability takes place, and the fluid in the blood vessels leak out, causing hypotension. Pressor drugs cause vascular constriction and reverses the vascular permeability.

To understand vascular permeability, imagine that the blood vessels have elevator-like doors that open quickly when cytokines are present. Nature has designed it so that when there is an injury like a sprained ankle, the injured tissues release cytokines that open the doors. The doors allow white blood cells and other repair nutrients to get to the sight of an injury and start the healing process. In the case of food allergies, all the elevator doors throughout the body open immediately, but in the case of sepsis, they slowly and gradually open. The pressor drugs (epinephrine) closes these doors.

Sepsis is usually triggered by Gram-positive bacterial pathogens in the skin and upper respiratory system.¹ Occasionally sepsis can be cause by gram-negative pathogens in the urine.

During the cold and flu season there is always cases of young healthy people dying of sepsis. It’s important for pharmacists to be on high alert to the early signs of sepsis.

Sepsis most commonly occurs in people with a secondary bacterial infection in the upper respiratory system. These people can also have the flu virus, but viruses don't usually trigger sepsis on their own.

LL's case is based on a true story where a 21-year-old body builder died of sepsis. No one is immune to sepsis. It can happen in anyone regardless of health status. Just like with food allergies, they can happen to people with extraordinary great health.²

REFERENCES

• Martin GS. Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes. Expert Rev Anti Infect Ther. 2012;10(6):701-706. Doi:10.1586/eri.12.50
• Von Wildenradt R. A 21-Year-Old Bodybuilder Suddenly Died from Flu Complications—Here’s What You Need to Know. Men’ Health online. https://www.menshealth.com/trending-news/a19546394/21-year-old-bodybuilder-dies-septic-shock-influenza/ Published January 10, 2018. Accessed August 24, 2020.