Obstructive urinary tract infection–related septic shock in late pregnancy complicated by β-thalassemia intermedia and whipworm infection: a case report

Obstructive urinary tract infection–related septic shock in late pregnancy complicated by β-thalassemia intermedia and whipworm infection: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Obstructive urinary tract infection–related septic shock in late pregnancy complicated by β-thalassemia intermedia and whipworm infection: a case report Min Chen, Chuang Chen, Wei-ying Liu, Bo Xi, Dong-yu Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8723342/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted 20 You are reading this latest preprint version Abstract Background: Sepsis is a leading cause of maternal mortality. Diagnosis in pregnancy is often delayed by non-specific presentation and legitimate caution regarding diagnostic imaging.This case illustrates a compounded diagnostic challenge: septic shock in a migrant patient, where unfamiliar, endemic comorbidities obscured the typical clinical picture. Case presentation: An 18-year-old primigravida at 27 weeks’ gestation presented with fever and mild respiratory symptoms, rapidly progressing to septic shock. Initial labs revealed severe microcytic anemia (Hb 59 g/L), marked hyperbilirubinemia, and leukocytosis. A low-dose abdominopelvic CT, crucial for source identification, revealed right-sided obstructive uropathy. This led to a diagnosis of obstructive pyelonephritis as the septic focus, managed with urgent ureteral stenting and antibiotics. Further investigation unmasked two underlying conditions contributing to her severe anemia: homozygous β-thalassemia intermedia and chronic Trichuris trichiura infection. The jaundice was attributed to sepsis-induced hepatocellular dysfunction. Following source control, transfusions, and supportive care, both maternal and fetal conditions stabilized. Conclusion: This case underscores that in pregnant patients with sepsis and atypical laboratory findings, timely imaging for source control is paramount. It also highlights the critical need to consider region-specific hereditary and parasitic diseases in the differential diagnosis for migrant populations, as these can significantly complicate the clinical presentation and management. Septic shock Pregnancy Obstructive pyelonephritis Urinary tract infection β-thalassemia Trichuris trichiura Anemia Hyperbilirubinemia Diagnostic imaging Migrant health Figures Figure 1 Background Sepsis remains a leading cause of maternal death [ 1 ]. In pregnancy, physiological adaptations and restrictions on imaging and antimicrobial use often delay both diagnosis and source control. We report the case of an 18-year-old woman at 26 + 6 weeks’ gestation who developed septic shock secondary to an obstructive urinary tract infection after initially presenting with fever and respiratory symptoms. Her clinical course was further complicated by previously unrecognized β-thalassemia intermedia and Trichuris trichiura infection, which broadened the differential diagnosis for her severe anemia and hyperbilirubinemia. Our hospital is located in Yancheng, Jiangsu Province in eastern China, where β-thalassemia and soil-transmitted helminth infections are rarely seen in obstetric practice, whereas the patient had recently migrated from rural Yunnan Province in southwestern China, where hemoglobinopathies and soil-transmitted helminth infections remain relatively prevalent [ 2 ], creating an epidemiologic mismatch that contributed to the diagnostic challenge. This case highlights the diagnostic and therapeutic difficulties of managing sepsis in mid- to late pregnancy when such uncommon underlying conditions coexist and underscores the importance of systematic screening for occult infectious foci, timely use of fetal-safe imaging, and a structured evaluation of anemia and hyperbilirubinemia. Case presentation and clinical course An 18-year-old primigravida Lisu woman at 26 + 6 weeks’ gestation, with a body mass index of 17.8 kg/m², presented to our obstetrics department on September 1 with a 12-day history of fever, dizziness, and a cough productive of scant white sputum. She reported chills and a peak temperature of 39.5°C after being caught in the rain, and had self-medicated with oral amoxicillin and ibuprofen without relief. At a local hospital, her temperature was 38.4°C, and laboratory tests revealed leukocytosis (white blood cell [WBC] count 26.4×10⁹/L), anemia (hemoglobin 73 g/L), thrombocytosis, and markedly elevated inflammatory markers (C-reactive protein [CRP] 171 mg/L, procalcitonin [PCT] 7.8 ng/mL). On admission to our hospital, she appeared markedly pale with mild scleral and cutaneous jaundice. Her vital signs were as follows: temperature 36.2°C, heart rate 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 102/74 mmHg. Arterial blood gas analysis, performed while she was receiving low-flow oxygen via nasal cannula, showed respiratory alkalosis with preserved oxygenation (pH 7.51, Pa CO₂ 23 mmHg, Pa O₂ 168 mmHg, lactate 2.6 mmol/L, Sa O₂ 99.2%). Repeat laboratory testing confirmed marked leukocytosis with neutrophilia (WBC 28.9×10⁹/L, neutrophils 88.8%), microcytic anemia (hemoglobin 59 g/L, mean corpuscular volume 63.6 fL), and elevated inflammatory and cholestatic markers (CRP 169 mg/L, interleukin-6 [IL-6] 83.9 pg/mL, total bilirubin 105 umol/L, direct bilirubin 59 umol/L, alanine aminotransferase 60 U/L). Initial management consisted of red blood cell transfusion and empirical intravenous cefoxitin, with close maternal observation and continuous fetal heart rate surveillance. Clinical deterioration and imaging evaluation At 07:00 on 2 September, she developed recurrent high-grade fever (40°C) with hypotension (88/48 mmHg) and tachycardia (130 beats/min) and was transferred to the intensive care unit (ICU). In the absence of a clearly localized source of infection on physical examination and initial laboratory tests, and given her new hemodynamic instability, urgent cross-sectional imaging was considered essential to guide source control. After multidisciplinary discussion among the obstetrics, intensive care, and radiology teams, we proceeded with a non-contrast CT of the abdomen and pelvis, with exposure kept as low as reasonably achievable, in accordance with current recommendations that clinically indicated imaging should not be withheld in pregnancy when it is expected to affect maternal management [ 3 ]. The anticipated benefit of promptly identifying a potentially obstructive urinary or intra-abdominal focus was judged to outweigh the small fetal radiation risk in the late second trimester. CT confirmed an intrauterine pregnancy and demonstrated right-sided ureteral and pelvicalyceal dilatation(Fig. 1 A), a left renal calculus, a caudate lobe configuration described as “rat-tail liver” (Fig. 1 B), scattered intrahepatic calcifications, and features consistent with an “anemic heart.” ICU course: management and stratified diagnostic evaluation Septic shock: identification and control of the infectious source On ICU admission, laboratory tests again showed marked leukocytosis and elevated CRP, PCT, and IL-6, consistent with sepsis and septic shock. A sepsis bundle was initiated immediately, including early fluid resuscitation, collection of blood cultures, administration of cefoperazone/sulbactam within 1 hour as a broad-spectrum regimen considered relatively safe for the fetus, and a systematic, parallel search for the infectious source. Although the illness had started with fever and respiratory symptoms, tests for influenza A and B antigens, SARS-CoV-2 nucleic acid, and common respiratory pathogens were all negative, and chest CT showed no definite infectious lesions; a respiratory source was therefore considered unlikely. For the urinary tract, physiological changes in the late second trimester—including hormonal effects, uterine compression, and altered urine composition—markedly increase the risk of urinary tract infection [ 4 ]. In this patient, urinalysis revealed occult blood, strongly positive leukocyte esterase, and 526 leukocytes/uL. CT demonstrated right-sided ureteral and pelvicalyceal dilatation with a left renal calculus. Emergency urological consultation led to a diagnosis of obstructive urolithiasis with infection and septic shock, and urgent urinary drainage was recommended. On the same day, bilateral ureteral stents were placed under local anesthesia; purulent urine drained from the right ureter confirmed the urinary tract as the primary focus of infection. Inflammatory markers subsequently decreased: on 3 September, the WBC count had fallen to 18.14×10⁹/L with 86.4% neutrophils, PCT to 2.29 ng/mL, and IL-6 to 40.95 pg/mL; on 5 September, midstream urine culture grew Escherichia coli (3×10 5 CFU/mL). Other potential sources, including genital tract, hepatobiliary, gastrointestinal, and skin or soft-tissue infection, were not supported by obstetric examination or abdominal and skin assessment. A bloodstream infection was also considered. Because blood cultures have a non-negligible false-negative rate (approximately 17.85%–18.4%) and are limited by turnaround time [ 5 ], we discussed the options with the family and the same admission blood samples were also submitted for a targeted metagenomic sequencing panel covering more than 300 pathogens. On 3 September, sequencing detected Escherichia coli (27 reads) and Klebsiella aerogenes (95 reads). Both are common uropathogens and, in the context of a documented urinary tract infection, strongly suggested urinary source bacteremia due to retrograde translocation of uropathogens into the bloodstream, further confirming the urinary tract as the source of sepsis. Blood cultures obtained on 7 September were negative. After initiation of cefoperazone/sulbactam and bilateral ureteral stenting, the patient’s peak temperature decreased and the WBC count and other inflammatory markers improved markedly. In view of the potential toxicity of alternative agents and concerns regarding maternal and fetal safety, the antimicrobial regimen was not modified, and cefoperazone/sulbactam was continued. By 5 September, when she was discharged from the ICU, she was afebrile, with a WBC count of 10.51×10⁹/L, neutrophils 74.6%, high-sensitivity CRP 23.43 mg/L, and PCT 0.86 ng/mL (Fig. 1 C). Severe anemia: multi-factorial etiology On admission, her hemoglobin level was 59 g/L, consistent with severe anemia. This prompted a systematic workup for both general and pregnancy-related causes of anemia. Physiologic hemodilution of pregnancy was considered first but was insufficient to explain this degree of anemia. Iron deficiency anemia was thought to be unlikely because there was no history of chronic or overt blood loss, serum ferritin was markedly elevated at 600.69 ng/mL, and the red blood cell indices were not typical of simple iron deficiency. Megaloblastic anemia was also excluded, as serum folate (2.82 ng/mL) and vitamin B₁₂ (252.31 pg/mL) levels did not suggest folate or vitamin B₁₂ deficiency. Her Lisu ethnicity and prior residence in rural Yunnan Province, where hemoglobinopathies are relatively prevalent, strongly suggested a hereditary anemia. Targeted genetic testing showed no abnormalities in the α-globin genes but revealed a homozygous CD26 (GAG > AAG) variant in the β-globin gene (β⁺/β⁺), consistent with β-thalassemia intermedia. Parasitic infection and chronic disease were also considered in the differential diagnosis. The patient reported a long-standing habit of drinking untreated water. On September 2, a stool examination for ova and parasites demonstrated Trichuris trichiura (Fig. 1 D); repeat specimens collected on three consecutive days remained positive, confirming whipworm infection. Chronic whipworm infection is associated with low-grade intestinal inflammation, nutritional compromise, and impaired erythropoiesis and, in heavy infections, can lead to clinically significant anemia. Indirect hyperbilirubinemia initially prompted an evaluation for hemolysis. However, she had no dark (cola-colored) urine or hepatosplenomegaly, the direct antiglobulin test was negative, and peripheral blood smear, bone marrow examination, and immunophenotyping for hematologic malignancy were all unremarkable, arguing against hemolysis. Her severe anemia was considered multifactorial, reflecting pregnancy-related hemodilution on a background of β-thalassemia intermedia and chronic whipworm infection. Because effective anthelmintic agents are either contraindicated in pregnancy (thiabendazole) or lack robust safety data in the second trimester (albendazole), we deferred deworming and instead treated her with red blood cell transfusion and folate supplementation. Her hemoglobin rose to 82 g/L by September 5, after a total of 6 units of packed red blood cells were transfused during hospitalization. Jaundice: sepsis-related hepatocellular dysfunction Other pregnancy-related causes of jaundice were unlikely. She had no pruritus, normal platelet and coagulation tests, negative viral and autoimmune serologies, and abdominal CT showed no biliary pathology; hemolysis was also excluded. The “rat-tail liver” appearance was regarded as an incidental anatomic variant. In the setting of sepsis with markedly raised inflammatory markers, predominantly indirect hyperbilirubinemia, and only mild transaminase elevation, we attributed the jaundice to sepsis-related hepatocellular dysfunction with impaired bilirubin handling. After source control and standard sepsis treatment, with adjunctive S-adenosyl-L-methionine as hepatoprotective therapy, total bilirubin fell from 105 umol/L on admission to 34.3 umol/L, in parallel with clinical improvement. Outcome and follow-up After transfer from ICU, she remained on antimicrobial therapy and received ongoing transfusion support. Albendazole was given from 11–13 September. Repeat stool microscopy on 14 September showed no ova or parasites. She was discharged on 16 September with hemoglobin 90 g/L and normal liver biochemistry. At the 2-week clinic review, she was well and afebrile; hemoglobin had risen to 103 g/L, WBC count was 10.11×10⁹/L, stool microscopy remained negative, and liver tests were unchanged. Serial fetal ultrasound and fetal heart rate assessment were reassuring throughout follow-up. Discussion Sepsis in pregnancy often presents with non-specific symptoms and a misleading focus. In this patient, fever and respiratory complaints initially suggested pneumonia. Repeated reassessment and early CT imaging revealed obstructive urolithiasis with purulent drainage as the source of septic shock. This use of CT to guide ureteral stenting and source control is consistent with the principle that necessary imaging in pregnancy should not be withheld when it is likely to alter maternal management [ 6 ]. At the same time, severe anemia and jaundice further clouded the clinical picture. Stepwise evaluation excluded physiological hemodilution, iron deficiency, pregnancy-specific liver disease, viral hepatitis, and hemolysis. Instead, it revealed β-thalassemia intermedia and chronic Trichuris trichiura infection in this migrant woman from an endemic area. The biochemical profile was most consistent with sepsis-related hepatocellular dysfunction. For clinicians, this case underscores that in pregnant women with sepsis and atypical hematologic or hepatic abnormalities, it is important to search actively for occult urinary obstruction and to consider region-specific hereditary and parasitic conditions in mobile populations within a multidisciplinary framework to protect both maternal and fetal outcomes. Declarations Ethics approval and consent to participate Not applicable. Consent statement The authors declare that informed consent was obtained for the usage of de-identified images and relevant investigations of the patient. Consent to publish Not applicable. Competing interests The authors declare no competing interests. Funding No Funding. Author Contribution Min Chen and Dong-Yu Chen contributed to the clinical management of the patient and drafting of the manuscript,Chuang Chen and Wei-ying Liu contributed to data collection and preparation of the clinical documentation, Bo Xi contributed to patient evaluation and revision of the manuscript.All authors read and approved the final manuscript. Acknowledgements Not applicable. Data Availability Not applicable. References Cresswell JA, Alexander M, Chong MYC, et al. Global and regional causes of maternal deaths 2009-20: a WHO systematic analysis. Lancet Glob Health. 2025;13(4):e626–34. 10.1016/S2214-109X(24)00560-6 . Xu LQ, Yu SH, Jiang ZX, et al. Soil-transmitted helminthiases: nationwide survey in China. Bull World Health Organ. 1995;73(4):507–13. Kwan ML, Miglioretti DL, Marlow EC et al. Trends in Medical Imaging During Pregnancy in the United States and Ontario, Canada, 1996 to 2016. JAMA Netw Open. 2019;2(7):e197249. Published 2019 Jul 3. 10.1001/jamanetworkopen.2019.7249 Johnston CL, Johnston MJ, Corke A, Davies MC. A likely urinary tract infection in a pregnant woman. BMJ. 2017;357:j1777. 10.1136/bmj.j1777 . Published 2017 Apr 27. Lamy B, Sundqvist M, Idelevich EA, ESCMID Study Group for Bloodstream Infections. Endocarditis and Sepsis (ESGBIES). Bloodstream infections - Standard and progress in pathogen diagnostics. Clin Microbiol Infect. 2020;26(2):142–50. 10.1016/j.cmi.2019.11.017 . Tirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics. 2015;35(6):1751–65. 10.1148/rg.2015150031 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 08 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviews received at journal 04 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviews received at journal 28 Feb, 2026 Reviews received at journal 27 Feb, 2026 Reviews received at journal 26 Feb, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 16 Feb, 2026 Editor assigned by journal 06 Feb, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 28 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8723342","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":593499527,"identity":"e00893c5-34e5-4045-8bfb-7a5c9ab4957c","order_by":0,"name":"Min Chen","email":"","orcid":"","institution":"The Yancheng Clinical College of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Chen","suffix":""},{"id":593499528,"identity":"366a0e91-2ca8-48d4-86f4-00fe8769ae61","order_by":1,"name":"Chuang Chen","email":"","orcid":"","institution":"The People’s Hospital of Dongtai","correspondingAuthor":false,"prefix":"","firstName":"Chuang","middleName":"","lastName":"Chen","suffix":""},{"id":593499529,"identity":"0335612a-3832-4e6e-b9e9-0a89557d179d","order_by":2,"name":"Wei-ying Liu","email":"","orcid":"","institution":"The Yancheng Clinical College of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei-ying","middleName":"","lastName":"Liu","suffix":""},{"id":593499530,"identity":"c0b51fa0-dccc-4b34-840f-a4175d4a1a55","order_by":3,"name":"Bo Xi","email":"","orcid":"","institution":"The Yancheng Clinical College of Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Xi","suffix":""},{"id":593499531,"identity":"2f99cd76-7c8a-47da-bc32-73d2e5d4ebbf","order_by":4,"name":"Dong-yu Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYBACNvnjBx98MJCwY2Pm//ggoaKGsBY+CZ5kwxkFNsn87A3GBg/OHCOsRU6CwUyY40Ma48yeA2aSD1uYiXCYdEMaM4PBYWaDGwlpFYkNbAz87d0J+LXIHDz2uMDgMB9Qy7EbiTtkGCTOnN2AXwtDQrrxDLAtiW03Es+wMRhI5BLUYibNY3CYccONZLaCxDZmIrRIgLWAvH+MjYE4LTxngIFsAArkHmaJhDPHeAj6Rb69HRiVf0BRycP48UdFjRx/ey9+LRiAhzTlo2AUjIJRMAqwAgDB+EnVfe6pswAAAABJRU5ErkJggg==","orcid":"","institution":"The First People’s Hospital of Yancheng","correspondingAuthor":true,"prefix":"","firstName":"Dong-yu","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2026-01-28 16:24:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8723342/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8723342/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-026-01220-2","type":"published","date":"2026-04-24T15:59:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":103166188,"identity":"13d97137-0dab-4d73-b4e4-4395431943e5","added_by":"auto","created_at":"2026-02-22 12:37:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":532740,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of imaging and laboratory examination characteristics of patients\u003c/p\u003e\n\u003cp\u003eA: Axial CT fusion image and corresponding CT image, showing dilation of the right ureter and renal pelvis (arrow head) \u0026nbsp;B: Axial CT image a due lobe configuration described as \u003cem\u003e\"rat tail liver\"\u003c/em\u003e (arrow head) \u0026nbsp;C:Dynamic monitoring of plasma concentrations of various inflammatory mediators during hospitalization of patients D: \u003cem\u003eTrichuris trichiura\u003c/em\u003e was found during routine fecal examination\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8723342/v1/6faebdf512a56306b7ca0831.jpg"},{"id":107928746,"identity":"a14fa34c-7e1b-46dd-81fe-c27fdfcf8181","added_by":"auto","created_at":"2026-04-27 16:12:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":679399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8723342/v1/071c5fa6-9116-4fa8-8696-65fae1f24fce.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Obstructive urinary tract infection–related septic shock in late pregnancy complicated by β-thalassemia intermedia and whipworm infection: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eSepsis remains a leading cause of maternal death [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In pregnancy, physiological adaptations and restrictions on imaging and antimicrobial use often delay both diagnosis and source control. We report the case of an 18-year-old woman at 26\u0026thinsp;+\u0026thinsp;6 weeks\u0026rsquo; gestation who developed septic shock secondary to an obstructive urinary tract infection after initially presenting with fever and respiratory symptoms. Her clinical course was further complicated by previously unrecognized β-thalassemia intermedia and \u003cem\u003eTrichuris trichiura\u003c/em\u003e infection, which broadened the differential diagnosis for her severe anemia and hyperbilirubinemia. Our hospital is located in Yancheng, Jiangsu Province in eastern China, where β-thalassemia and soil-transmitted helminth infections are rarely seen in obstetric practice, whereas the patient had recently migrated from rural Yunnan Province in southwestern China, where hemoglobinopathies and soil-transmitted helminth infections remain relatively prevalent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], creating an epidemiologic mismatch that contributed to the diagnostic challenge. This case highlights the diagnostic and therapeutic difficulties of managing sepsis in mid- to late pregnancy when such uncommon underlying conditions coexist and underscores the importance of systematic screening for occult infectious foci, timely use of fetal-safe imaging, and a structured evaluation of anemia and hyperbilirubinemia.\u003c/p\u003e"},{"header":"Case presentation and clinical course","content":"\u003cp\u003eAn 18-year-old primigravida Lisu woman at 26\u0026thinsp;+\u0026thinsp;6 weeks\u0026rsquo; gestation, with a body mass index of 17.8 kg/m\u0026sup2;, presented to our obstetrics department on September 1 with a 12-day history of fever, dizziness, and a cough productive of scant white sputum. She reported chills and a peak temperature of 39.5\u0026deg;C after being caught in the rain, and had self-medicated with oral amoxicillin and ibuprofen without relief. At a local hospital, her temperature was 38.4\u0026deg;C, and laboratory tests revealed leukocytosis (white blood cell [WBC] count 26.4\u0026times;10⁹/L), anemia (hemoglobin 73 g/L), thrombocytosis, and markedly elevated inflammatory markers (C-reactive protein [CRP] 171 mg/L, procalcitonin [PCT] 7.8 ng/mL).\u003c/p\u003e \u003cp\u003eOn admission to our hospital, she appeared markedly pale with mild scleral and cutaneous jaundice. Her vital signs were as follows: temperature 36.2\u0026deg;C, heart rate 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 102/74 mmHg. Arterial blood gas analysis, performed while she was receiving low-flow oxygen via nasal cannula, showed respiratory alkalosis with preserved oxygenation (pH 7.51, Pa CO₂ 23 mmHg, Pa O₂ 168 mmHg, lactate 2.6 mmol/L, Sa O₂ 99.2%). Repeat laboratory testing confirmed marked leukocytosis with neutrophilia (WBC 28.9\u0026times;10⁹/L, neutrophils 88.8%), microcytic anemia (hemoglobin 59 g/L, mean corpuscular volume 63.6 fL), and elevated inflammatory and cholestatic markers (CRP 169 mg/L, interleukin-6 [IL-6] 83.9 pg/mL, total bilirubin 105 umol/L, direct bilirubin 59 umol/L, alanine aminotransferase 60 U/L). Initial management consisted of red blood cell transfusion and empirical intravenous cefoxitin, with close maternal observation and continuous fetal heart rate surveillance.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eClinical deterioration and imaging evaluation\u003c/h2\u003e \u003cp\u003eAt 07:00 on 2 September, she developed recurrent high-grade fever (40\u0026deg;C) with hypotension (88/48 mmHg) and tachycardia (130 beats/min) and was transferred to the intensive care unit (ICU). In the absence of a clearly localized source of infection on physical examination and initial laboratory tests, and given her new hemodynamic instability, urgent cross-sectional imaging was considered essential to guide source control. After multidisciplinary discussion among the obstetrics, intensive care, and radiology teams, we proceeded with a non-contrast CT of the abdomen and pelvis, with exposure kept as low as reasonably achievable, in accordance with current recommendations that clinically indicated imaging should not be withheld in pregnancy when it is expected to affect maternal management [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The anticipated benefit of promptly identifying a potentially obstructive urinary or intra-abdominal focus was judged to outweigh the small fetal radiation risk in the late second trimester.\u003c/p\u003e \u003cp\u003eCT confirmed an intrauterine pregnancy and demonstrated right-sided ureteral and pelvicalyceal dilatation(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), a left renal calculus, a caudate lobe configuration described as \u0026ldquo;rat-tail liver\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB), scattered intrahepatic calcifications, and features consistent with an \u0026ldquo;anemic heart.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eICU course: management and stratified diagnostic evaluation\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSeptic shock: identification and control of the infectious source\u003c/h2\u003e \u003cp\u003eOn ICU admission, laboratory tests again showed marked leukocytosis and elevated CRP, PCT, and IL-6, consistent with sepsis and septic shock. A sepsis bundle was initiated immediately, including early fluid resuscitation, collection of blood cultures, administration of cefoperazone/sulbactam within 1 hour as a broad-spectrum regimen considered relatively safe for the fetus, and a systematic, parallel search for the infectious source.\u003c/p\u003e \u003cp\u003eAlthough the illness had started with fever and respiratory symptoms, tests for influenza A and B antigens, SARS-CoV-2 nucleic acid, and common respiratory pathogens were all negative, and chest CT showed no definite infectious lesions; a respiratory source was therefore considered unlikely. For the urinary tract, physiological changes in the late second trimester\u0026mdash;including hormonal effects, uterine compression, and altered urine composition\u0026mdash;markedly increase the risk of urinary tract infection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this patient, urinalysis revealed occult blood, strongly positive leukocyte esterase, and 526 leukocytes/uL. CT demonstrated right-sided ureteral and pelvicalyceal dilatation with a left renal calculus. Emergency urological consultation led to a diagnosis of obstructive urolithiasis with infection and septic shock, and urgent urinary drainage was recommended. On the same day, bilateral ureteral stents were placed under local anesthesia; purulent urine drained from the right ureter confirmed the urinary tract as the primary focus of infection. Inflammatory markers subsequently decreased: on 3 September, the WBC count had fallen to 18.14\u0026times;10⁹/L with 86.4% neutrophils, PCT to 2.29 ng/mL, and IL-6 to 40.95 pg/mL; on 5 September, midstream urine culture grew \u003cem\u003eEscherichia coli\u003c/em\u003e (3\u0026times;10\u003csup\u003e5\u003c/sup\u003e CFU/mL).\u003c/p\u003e \u003cp\u003eOther potential sources, including genital tract, hepatobiliary, gastrointestinal, and skin or soft-tissue infection, were not supported by obstetric examination or abdominal and skin assessment.\u003c/p\u003e \u003cp\u003eA bloodstream infection was also considered. Because blood cultures have a non-negligible false-negative rate (approximately 17.85%\u0026ndash;18.4%) and are limited by turnaround time [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], we discussed the options with the family and the same admission blood samples were also submitted for a targeted metagenomic sequencing panel covering more than 300 pathogens. On 3 September, sequencing detected \u003cem\u003eEscherichia coli\u003c/em\u003e (27 reads) and \u003cem\u003eKlebsiella aerogenes\u003c/em\u003e (95 reads). Both are common uropathogens and, in the context of a documented urinary tract infection, strongly suggested urinary source bacteremia due to retrograde translocation of uropathogens into the bloodstream, further confirming the urinary tract as the source of sepsis. Blood cultures obtained on 7 September were negative. After initiation of cefoperazone/sulbactam and bilateral ureteral stenting, the patient\u0026rsquo;s peak temperature decreased and the WBC count and other inflammatory markers improved markedly. In view of the potential toxicity of alternative agents and concerns regarding maternal and fetal safety, the antimicrobial regimen was not modified, and cefoperazone/sulbactam was continued. By 5 September, when she was discharged from the ICU, she was afebrile, with a WBC count of 10.51\u0026times;10⁹/L, neutrophils 74.6%, high-sensitivity CRP 23.43 mg/L, and PCT 0.86 ng/mL (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSevere anemia: multi-factorial etiology\u003c/h3\u003e\n\u003cp\u003eOn admission, her hemoglobin level was 59 g/L, consistent with severe anemia. This prompted a systematic workup for both general and pregnancy-related causes of anemia.\u003c/p\u003e \u003cp\u003ePhysiologic hemodilution of pregnancy was considered first but was insufficient to explain this degree of anemia. Iron deficiency anemia was thought to be unlikely because there was no history of chronic or overt blood loss, serum ferritin was markedly elevated at 600.69 ng/mL, and the red blood cell indices were not typical of simple iron deficiency. Megaloblastic anemia was also excluded, as serum folate (2.82 ng/mL) and vitamin B₁₂ (252.31 pg/mL) levels did not suggest folate or vitamin B₁₂ deficiency.\u003c/p\u003e \u003cp\u003eHer Lisu ethnicity and prior residence in rural Yunnan Province, where hemoglobinopathies are relatively prevalent, strongly suggested a hereditary anemia. Targeted genetic testing showed no abnormalities in the α-globin genes but revealed a homozygous CD26 (GAG\u0026thinsp;\u0026gt;\u0026thinsp;AAG) variant in the β-globin gene (β⁺/β⁺), consistent with β-thalassemia intermedia.\u003c/p\u003e \u003cp\u003eParasitic infection and chronic disease were also considered in the differential diagnosis. The patient reported a long-standing habit of drinking untreated water. On September 2, a stool examination for ova and parasites demonstrated \u003cem\u003eTrichuris trichiura\u003c/em\u003e (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD); repeat specimens collected on three consecutive days remained positive, confirming whipworm infection. Chronic whipworm infection is associated with low-grade intestinal inflammation, nutritional compromise, and impaired erythropoiesis and, in heavy infections, can lead to clinically significant anemia. Indirect hyperbilirubinemia initially prompted an evaluation for hemolysis. However, she had no dark (cola-colored) urine or hepatosplenomegaly, the direct antiglobulin test was negative, and peripheral blood smear, bone marrow examination, and immunophenotyping for hematologic malignancy were all unremarkable, arguing against hemolysis.\u003c/p\u003e \u003cp\u003eHer severe anemia was considered multifactorial, reflecting pregnancy-related hemodilution on a background of β-thalassemia intermedia and chronic whipworm infection. Because effective anthelmintic agents are either contraindicated in pregnancy (thiabendazole) or lack robust safety data in the second trimester (albendazole), we deferred deworming and instead treated her with red blood cell transfusion and folate supplementation. Her hemoglobin rose to 82 g/L by September 5, after a total of 6 units of packed red blood cells were transfused during hospitalization.\u003c/p\u003e\n\u003ch3\u003eJaundice: sepsis-related hepatocellular dysfunction\u003c/h3\u003e\n\u003cp\u003eOther pregnancy-related causes of jaundice were unlikely. She had no pruritus, normal platelet and coagulation tests, negative viral and autoimmune serologies, and abdominal CT showed no biliary pathology; hemolysis was also excluded. The \u0026ldquo;rat-tail liver\u0026rdquo; appearance was regarded as an incidental anatomic variant. In the setting of sepsis with markedly raised inflammatory markers, predominantly indirect hyperbilirubinemia, and only mild transaminase elevation, we attributed the jaundice to sepsis-related hepatocellular dysfunction with impaired bilirubin handling. After source control and standard sepsis treatment, with adjunctive S-adenosyl-L-methionine as hepatoprotective therapy, total bilirubin fell from 105 umol/L on admission to 34.3 umol/L, in parallel with clinical improvement.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome and follow-up\u003c/h2\u003e \u003cp\u003eAfter transfer from ICU, she remained on antimicrobial therapy and received ongoing transfusion support. Albendazole was given from 11\u0026ndash;13 September. Repeat stool microscopy on 14 September showed no ova or parasites. She was discharged on 16 September with hemoglobin 90 g/L and normal liver biochemistry. At the 2-week clinic review, she was well and afebrile; hemoglobin had risen to 103 g/L, WBC count was 10.11\u0026times;10⁹/L, stool microscopy remained negative, and liver tests were unchanged. Serial fetal ultrasound and fetal heart rate assessment were reassuring throughout follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSepsis in pregnancy often presents with non-specific symptoms and a misleading focus. In this patient, fever and respiratory complaints initially suggested pneumonia. Repeated reassessment and early CT imaging revealed obstructive urolithiasis with purulent drainage as the source of septic shock. This use of CT to guide ureteral stenting and source control is consistent with the principle that necessary imaging in pregnancy should not be withheld when it is likely to alter maternal management [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the same time, severe anemia and jaundice further clouded the clinical picture. Stepwise evaluation excluded physiological hemodilution, iron deficiency, pregnancy-specific liver disease, viral hepatitis, and hemolysis. Instead, it revealed β-thalassemia intermedia and chronic \u003cem\u003eTrichuris trichiura\u003c/em\u003e infection in this migrant woman from an endemic area. The biochemical profile was most consistent with sepsis-related hepatocellular dysfunction. For clinicians, this case underscores that in pregnant women with sepsis and atypical hematologic or hepatic abnormalities, it is important to search actively for occult urinary obstruction and to consider region-specific hereditary and parasitic conditions in mobile populations within a multidisciplinary framework to protect both maternal and fetal outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent statement\u003c/h2\u003e \u003cp\u003e The authors declare that informed consent was obtained for the usage of de-identified images and relevant investigations of the patient.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent to publish\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo Funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMin Chen and Dong-Yu Chen contributed to the clinical management of the patient and drafting of the manuscript,Chuang Chen and Wei-ying Liu contributed to data collection and preparation of the clinical documentation, Bo Xi contributed to patient evaluation and revision of the manuscript.All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCresswell JA, Alexander M, Chong MYC, et al. Global and regional causes of maternal deaths 2009-20: a WHO systematic analysis. Lancet Glob Health. 2025;13(4):e626\u0026ndash;34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(24)00560-6\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(24)00560-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu LQ, Yu SH, Jiang ZX, et al. Soil-transmitted helminthiases: nationwide survey in China. Bull World Health Organ. 1995;73(4):507\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwan ML, Miglioretti DL, Marlow EC et al. Trends in Medical Imaging During Pregnancy in the United States and Ontario, Canada, 1996 to 2016. JAMA Netw Open. 2019;2(7):e197249. Published 2019 Jul 3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2019.7249\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2019.7249\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnston CL, Johnston MJ, Corke A, Davies MC. A likely urinary tract infection in a pregnant woman. BMJ. 2017;357:j1777. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.j1777\u003c/span\u003e\u003cspan address=\"10.1136/bmj.j1777\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2017 Apr 27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLamy B, Sundqvist M, Idelevich EA, ESCMID Study Group for Bloodstream Infections. Endocarditis and Sepsis (ESGBIES). Bloodstream infections - Standard and progress in pathogen diagnostics. Clin Microbiol Infect. 2020;26(2):142\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cmi.2019.11.017\u003c/span\u003e\u003cspan address=\"10.1016/j.cmi.2019.11.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics. 2015;35(6):1751\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/rg.2015150031\u003c/span\u003e\u003cspan address=\"10.1148/rg.2015150031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Septic shock, Pregnancy, Obstructive pyelonephritis, Urinary tract infection, β-thalassemia, Trichuris trichiura, Anemia, Hyperbilirubinemia, Diagnostic imaging, Migrant health","lastPublishedDoi":"10.21203/rs.3.rs-8723342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8723342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Sepsis is a leading cause of maternal mortality. Diagnosis in pregnancy is often delayed by non-specific presentation and legitimate caution regarding diagnostic imaging.This case illustrates a compounded diagnostic challenge: septic shock in a migrant patient, where unfamiliar, endemic comorbidities obscured the typical clinical picture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e An 18-year-old primigravida at 27 weeks’ gestation presented with fever and mild respiratory symptoms, rapidly progressing to septic shock. Initial labs revealed severe microcytic anemia (Hb 59 g/L), marked hyperbilirubinemia, and leukocytosis. A low-dose abdominopelvic CT, crucial for source identification, revealed right-sided obstructive uropathy. This led to a diagnosis of obstructive pyelonephritis as the septic focus, managed with urgent ureteral stenting and antibiotics. Further investigation unmasked two underlying conditions contributing to her severe anemia: homozygous β-thalassemia intermedia and chronic \u003cem\u003eTrichuris trichiura\u003c/em\u003e infection. The jaundice was attributed to sepsis-induced hepatocellular dysfunction. Following source control, transfusions, and supportive care, both maternal and fetal conditions stabilized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This case underscores that in pregnant patients with sepsis and atypical laboratory findings, timely imaging for source control is paramount. It also highlights the critical need to consider region-specific hereditary and parasitic diseases in the differential diagnosis for migrant populations, as these can significantly complicate the clinical presentation and management.\u003c/p\u003e","manuscriptTitle":"Obstructive urinary tract infection–related septic shock in late pregnancy complicated by β-thalassemia intermedia and whipworm infection: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 12:37:33","doi":"10.21203/rs.3.rs-8723342/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T03:48:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T13:33:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312820674242382342033072184297269087858","date":"2026-03-04T21:42:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T19:03:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241629389429887125602718239071776457494","date":"2026-03-04T18:59:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47246747091053516192910596308128604010","date":"2026-03-02T15:22:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T12:32:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-27T06:31:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T06:49:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29371143330171923441604397372672020340","date":"2026-02-25T18:28:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141266852091346125393444647150237629413","date":"2026-02-25T15:47:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82518561790404969105665730607881080663","date":"2026-02-25T15:25:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T15:04:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247649420351615723157874731312915375417","date":"2026-02-19T14:31:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32321861512354301766277056870288297846","date":"2026-02-18T16:22:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186553218940702215165852365078650992736","date":"2026-02-17T13:43:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-16T13:20:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-06T09:59:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-06T09:56:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2026-01-28T15:31:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0f8152dd-e563-40f5-ba99-a60ed86669fa","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:09:23+00:00","versionOfRecord":{"articleIdentity":"rs-8723342","link":"https://doi.org/10.1186/s12245-026-01220-2","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2026-04-24 15:59:33","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2026-02-22 12:37:33","video":"","vorDoi":"10.1186/s12245-026-01220-2","vorDoiUrl":"https://doi.org/10.1186/s12245-026-01220-2","workflowStages":[]},"version":"v1","identity":"rs-8723342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8723342","identity":"rs-8723342","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}