An unknown (and unexpected) cause of septic shock

An 80-year-old woman with end-stage renal disease on peritoneal dialysis presented with an episode of syncope. On arrival, the patient was hypotensive, tachycardic, tachypneic, and febrile to 100.2°F. The patient was alert and oriented to person only. There was no abdominal tenderness and her peritoneal catheter site was clean, dry, and intact. A computed tomography scan of her abdomen and pelvis was conducted to rule out peritonitis (Figure 1). Murky drainage was later noted to be present at the site of the patient's peritoneal dialysis catheter. A decision was made in consultation with surgery to perform an exploratory laparotomy. Murky and bilious fluid was found in the pelvis, and a pinhole defect with bilious leakage was identified in the proximal ileum in the left lower quadrant. A jellybean-like, non-obstructive nodule (later confirmed by pathology to be an indolent schwannoma) was also found 8 cm distal to the site of the perforation. A 4 cm fishbone was extracted from the small bowel, and 15 cm of the small bowel was resected to include the defect and the nodule (Figure 2). Few cases of septic shock from bowel perforation from ingested fish bones have been reported.1, 2 The presented case of a fish bone perforation of the ileum as a cause of septic shock underscores the importance of considering multiple etiologies in the setting of undifferentiated shock. The authors declare they have no conflicts of interest.