A Case of Severe Psittacosis Pneumonia Complicated by Splenic Infarction

A Case of Severe Psittacosis Pneumonia Complicated by Splenic Infarction | 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 A Case of Severe Psittacosis Pneumonia Complicated by Splenic Infarction Zhao Yu, Yuanyuan Qian, Lan Lv, Wenqing Hu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4583183/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted 13 You are reading this latest preprint version Abstract Psittacosis pneumonia, a zoonotic infectious disease transmitted from birds to humans, is caused by Chlamydia psittaci and represents a type of chlamydial pneumonia [1]. In severe instances, the disease may progress to critical pneumonia and respiratory failure, necessitating intensive support measures, including mechanical ventilation. The advent of technologies such as Metagenomic Next-Generation Sequencing (mNGS) for the etiological diagnosis of infectious diseases [2] has enhanced the diagnostic and treatment success rates for Psittacosis. Instances of severe chlamydial pneumonia with complications such as splenic infarction are uncommon. A patient with severe Psittacosis pneumonia complicated by splenic infarction was admitted to the Emergency Intensive Care Unit (EICU) of Haining People's Hospital and subsequently improved following effective anti-infective and anticoagulant therapy. This report and share are as follows. psittacosis splenic infarction critical pneumonia. Figures Figure 1 Figure 2 Figure 3 Figure 4 Clinical Data The patient, a 76-year-old female, was admitted to the hospital on June 4, 2023, presenting with a three-day history of fever and cough, which escalated to somnolence on the day prior to admission. Initially, she exhibited a fever peaking at 39°C and a paroxysmal dry cough without diurnal variation. Her condition deteriorated the following day, marked by altered consciousness and hypotension, with blood pressure dropping to 70/46 mmHg (1 mmHg = 1.33 kPa). She received interventions to elevate her blood pressure, alongside anti-infective treatment and fluid resuscitation. Her medical history included hypertension, but she denied any history of diabetes, atrial fibrillation, or cardiac valvular disease. Her occupational background in agriculture involved prolonged exposure to domestic poultry, and she reported no smoking or alcohol consumption. Physical examination: Respiratory rate: 22 breaths/min, heart rate: 81 beats/min, blood pressure: 121/77mmHg (Norepinephrine 10mg, 0.37ug/kg/min). Coarse breath sounds and scattered wet rales were noted in both lungs, while cardiac examination revealed a regular rhythm without significant arrhythmias or murmurs. The abdomen was distended without tenderness or rebound pain, and no obvious hepatosplenomegaly was palpable. Post-admission Comprehensive Examination: On 2023-06-04 (DAY1), arterial blood gas analysis showed pH of 7.37, PCO2 of 34.0 mmHg, PO2 of 78.0 mmHg under mask oxygenation, and an oxygen saturation of 95%. Emergency complete blood count and inflammatory markers showed a white blood cell count of 12.4×109/L, with a neutrophil percentage of 95.9% and lymphocyte percentage of 2.6%. The platelet count was 220×109/L, and high-sensitivity C-reactive protein (CRP) exceeded 370.0mg/L. Coagulation tests revealed a prothrombin time of 9.3 seconds, plasma fibrinogen of 9.22g/L, and D-dimer of 2.278µg/mL. Procalcitonin (PCT) and interleukin-6 (IL-6) levels were 9.58 ng/mL and 1391.1 pg/ml, respectively, while the nucleic acid test for the novel coronavirus returned negative. Chest and abdominal CT scans on the same day revealed pulmonary infection, with inflammation and partial consolidation in the upper and lower lobes of the right lung (Fig. 1 ). Upon admission, the patient's evaluations included: a Sequential Organ Failure Assessment (SOFA score) of 8 points; a CURB-65 score for community-acquired pneumonia of 3 points; a Pneumonia Severity Index (PSI) of 149 points, classifying as class V ,with a predicted mortality rate of 27%; and a Venous Thromboembolism (VTE) score - Padua Prediction Score of 6 points, indicating a high risk. Treatment: On the admission day (June 4, 2023), the patient, experiencing a reduction in oxygenation, was promptly intubated and placed on mechanical ventilation. Imipenem/cilastatin 0.5g every 8 hours combined with tigecycline 50mg every 12 hours was administered for anti-infection, along with enoxaparin 0.2 ml subcutaneously every 12 hours for anticoagulation, and treatments for expectoration and asthma relief. On June 7, 2023 (DAY 3), bronchoscopy was performed, and the lavage fluid was analyzed using mNGS at Zhejiang Shengting Medical Laboratory Co., Ltd., identifying a Chlamydia psittaci infection with 5434 sequence counts, with no viral RNA sequences detected the following day (June 8, 2023, DAY 4). Treatment was adjusted to moxifloxacin sodium chloride injection 0.4g daily with continued tigecycline 50mg every 12 hours for anti-infection, complemented by intermittent prone positioning ventilation and bronchoscopy suction among other supportive care measures. Subsequent treatment led to improvements in pulmonary function, enhanced oxygenation, and reduced inflammatory markers such as PCT and CRP. On June 12, 2023 (DAY 8), the patient reported concealed pain in the upper left abdomen with palpation tenderness but no muscle tension. Blood tests showed hemoglobin at 74 g/L, platelets at 60×109/L, fibrinogen at 0.64 g/L, and D-dimer at 35.682 µg/ml; an enhanced abdominal CT scan revealed Gerota's fascia effusion, splenic infarction, and abdominal pelvic effusion (Fig. 2 ). Following discussions at a Multi-Disciplinary Treatment (MDT) meeting, the patient was diagnosed with severe Psittacosis pneumonia complicated by splenic infarction. Given the absence of splenic abscess or rupture and no need for surgical intervention, conservative medical management was employed. Enoxaparin injections were substituted with rivaroxaban 10mg administered nasogastrically once daily for anticoagulation, complemented by supportive treatments including transfusions of fibrinogen, platelets, red blood cells, plasma, and cryoprecipitate. Subsequent to these interventions, the patient's abdominal pain subsided, inflammatory markers diminished, and oxygenation levels increased. Mechanical ventilation was ceased on June 16, 2023 (DAY 12), and the patient was transitioned to a regular ward with high-flow nasal oxygen. Post-discharge imaging revealed (Fig. 3 ) substantial resolution of pulmonary inflammatory lesions and improvement in the spleen's low-density lesions compared to prior assessments. The therapeutic approach during the hospital stay, evolution of the patient's condition, and discharge follow-up findings are illustrated in Fig. 4 . This study received approval from the Ethics Committee of Haining People's Hospital [Approval number: (2023) Ethics Review No. 118], and informed consent was duly obtained. Discussion Psittacosis, caused by Chlamydia psittaci of the Chlamydiaceae family, is an obligate intracellular parasite with 17 identified genotypes [ 3 ]. Transmission occurs through direct contact with infected birds, poultry, mammals, their feces, respiratory secretions, or contaminated aerosols. Psittacosis pneumonia represents about 1.03% of all community-acquired pneumonia cases worldwide [ 1 ], with epidemiological data from 21 countries across all continents indicating positivity rates between 0.34% and 93.8%. In China, reports have emerged from 16 provinces [ 3 ]. Clinically, symptoms range from asymptomatic to typical respiratory infection signs, with severe cases necessitating mechanical ventilation and intensive care. Radiographic findings include patchy consolidations or ground-glass opacities, bronchiectasis, and uni- or bilateral lung involvement. Severe instances often exhibit bronchial inflation, correlating with disease severity. Although blood tests like white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) can indicate anomalies, their lack of specificity contributes to frequent misdiagnoses or overlooked diagnoses with standard imaging and blood tests [ 4 ]. Definitive diagnosis hinges on isolating Chlamydia psittaci from respiratory or blood samples, but traditional culturing methods are slow, hindering timely diagnosis. However, recent adoption of metagenomic next-generation sequencing (mNGS) in infectious disease diagnosis enables rapid, untargeted sample testing within approximately 24 hours [ 2 , 5 ], facilitating swift antimicrobial treatment adjustments and enhancing treatment efficacy. Tetracyclines are typically the first-line treatment, with macrolides or fluoroquinolones as alternatives if tetracyclines are unsuitable [ 6 ]. Current research indicates that the psittacosis pathogen is sensitive to both quinolones and tetracyclines, with a high cure rate [ 7 ]. Splenic infarction (SI) is characterized by ischemic necrosis of the spleen due to obstruction of the splenic artery or its branches, potentially leading to serious complications such as splenic abscess, secondary infection, and significant hemorrhagic splenic rupture, posing a critical risk to patient survival. Clinically, it manifests as upper left abdominal pain, fever, chills, and nausea, though asymptomatic presentations are possible, increasing the risk of misdiagnosis or delayed diagnosis. In some instances, a definitive diagnosis is only achieved post-mortem via autopsy [ 8 ]. The literature has identified leukocytosis, lymphopenia, prolonged activated partial thromboplastin time, decreased fibrinogen, liver dysfunction, elevated LDH, and blood urea nitrogen as positive indicators of splenic infarction, serving as predictive factors for patient prognosis [ 9 ]. Several factors can cause splenic infarction: 1) Vascular diseases of the spleen due to the end-arterial nature of splenic artery branches, predisposing them to thrombosis from atherosclerosis, bending, or reduced blood flow with age; 2) Hypercoagulable states, such as those associated with pancreatic cancer or malignant lymphoma, which can induce thrombosis and subsequent infarction [ 10 ]; 3) Cardiac diseases like infective endocarditis, atrial fibrillation, and rheumatic heart disease can lead to cardiac valvular vegetations [ 11 ]; 4) Iatrogenic causes during vascular interventional procedures can lead to embolic agents inadvertently entering the splenic artery, causing ectopic embolisms [ 12 ]. In this case, despite anticoagulation prophylaxis during the treatment of confirmed psittacosis pneumonia, splenic infarction still occurred. The patient had no tumors, cardiac disease, or underlying hematological conditions, and ultrasound did not reveal portal vein system thrombosis or cardiac valvular vegetations, suggesting none of the aforementioned causes. Recent years have seen an uptick in case reports of splenic infarction associated with infections, as documented in both domestic and international literature. Researchers such as Childer, Hahn, and Yin Wenwen [ 13 – 15 ] have reported rare instances of splenic infarction linked to infections like COVID-19, Mycoplasma pneumoniae, and Brucella. However, reports of splenic infarction due to Chlamydia psittaci infection are nonexistent. Splenic infarctions related to severe infections are infrequently cited in clinical cases, with their underlying mechanisms still to be elucidated. One possible explanation is the formation of in-situ bacterial thrombi in the splenic artery caused by severe infections or thrombosis formation in a hypercoagulable state due to septic shock, which blocks the splenic artery. Additionally, infections can lead to endothelial dysfunction of vascular cells, triggering fibrin formation and platelet adhesion and aggregation, ultimately causing splenic artery thrombosis [ 16 ]. Further, evidence indicates that the interplay between coagulation pathways and the complement cascade in Mycoplasma pneumoniae infections could lead to infarctions across various anatomical sites [ 14 ]. Given that Chlamydia and Mycoplasma are atypical pathogens, the similarity of their thrombotic mechanisms in infections warrants additional investigation. This case marks the inaugural report of severe psittacosis pneumonia with concurrent splenic infarction. A review highlights the need to be vigilant for rare complications such as splenic infarction in severe cases of psittacosis pneumonia. Patients on mechanical ventilation, especially in sedated states, should not overlook changes in abdominal signs and vital signs. The detection of decreased fibrinogen and platelets, elevated D-dimer, and fluctuations in inflammatory markers, coagulation functions, and hematologic lab parameters should raise alerts for potential thrombotic or hemorrhagic occurrences. The causative link between severe psittacosis pneumonia and subsequent splenic infarction merits deeper investigative scrutiny. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Haining People's Hospital. Consent for publication Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article. Availability of data and material This study received approval from the Ethics Committee of Haining People's Hospital [Approval number: (2023) Ethics Review No. 118].Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article. Competing interests The authors report no conflicts of interest in this work. Funding No funding was received for this study. Author Contributions The authors listed in this article have made significant contributions to the work of the report. ZY is responsible for collecting medical records and writing papers；YYQ is responsible for collecting medical record data and processing images and tables；LL is responsible for literature search and organization；WQH is responsible for literature screening and guiding paper writing.All authors participated in drafting or writing, or substantially revised or critically reviewed the article, and have agreed on the journal in which the article will be submitted. Finally, all authors agree to take responsibility and be accountable for the contents of the article. References Hogerwerf L, DE Gier B, Baan B, et al. Chlamydia psittaci (psittacosis) as a cause of community-acquired pneumonia: a systematic review and meta-analysis. Epidemiol Infect. 2017;145(15):3096–105. 10.1017/S0950268817002060 . Li Ying M, Jinmin. Expert consensus on the clinical application of metagenomic sequencing technology in moderate to severe infections (First Edition) [J]. Infection, Inflammation, Repair, 2020;21(02):75–81. Li Wei G, Zhenxing LG, et al. Epidemiology and prevention progress of Chlamydophila psittaci infection in animals [J]. Adv Anim Med. 2023;44(06):105–10. 10.16437/j.cnki.1007-5038.2023.06.009 . Yang X, Liu Z, Liu X, et al. Chlamydia Psittaci Pneumonia-Induced Myocarditis: A Case Report. Infect Drug Resist. 2023;16:4259–64. 10.2147/IDR.S417241 . Li Wei Z, Chao X, Jiancheng, et al. Application of mNGS in laboratory and clinical settings [J]. Int J Lab Med. 2023;44(01):1–7. Zhang Y, Jiang Xiangsen Y, Wei, et al. Clinical features and outcome of eight patients with Chlamydia psittaci pneumonia diagnosed by targeted next-generation sequencing. Clin Respir J. 2023;17(9):915–30. 10.1111/crj.13681 . Epub 2023. PMID: 37552996; PMCID: PMC10500319. Yang F, Li J, Qi B, et al. Clinical Symptoms and Outcomes of Severe Pneumonia Caused by Chlamydia psittaci in Southwest China. Front Cell Infect Microbiol. 2022;11:727594. 10.3389/fcimb.2021.727594 . PMID: 35071027; PMCID: PMC8770948. Li Y, Juan ZJL. Analysis of clinical characteristics of 137 cases of splenic infarction. World Chin J Digestology. 2014;22(11):1607–11. Hakoshima M, Kitakaze K, Adachi H, et al. Clinical, Hematological, Biochemical, and Radiological Characteristics for Patients With Splenic Infarction: Case Series With Literature Review. J Clin Med Res. 2023;15(1):38–50. 10.14740/jocmr4836 . Epub 2023. PMID: 36755765; PMCID: PMC9881492. Schattner A, Adi M, Kitroser E, et al. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome. Med (Baltim). 2015;94(36):e1363. 10.1097/MD.0000000000001363 . PMID: 26356690; PMCID: PMC4616622. Li X, Lei R, Rui L. A case of splenic infarction caused by paroxysmal atrial fibrillation [J]. People's Military Surgeon. 2021;64(03):258–9. Zhao Baokui L, Gang M, Yanshou, et al. Iatrogenic splenic infarction: Three case reports and clinical analysis [J]. Mod Hosp. 2021;21(03):481–3. Childers J, Do TVC, Smith F, et al. Incidental and Asymptomatic Splenic Infarction and Infrarenal Thrombus in a COVID-19 Patient. Cureus. 2022;14(7):e26555. 10.7759/cureus.26555 . PMID: 35936145; PMCID: PMC9348832. Hahn DW, Atkinson CE, Le M. Multiple anatomic sites of infarction in a pediatric patient with M. pneumoniae infection, a case report. BMC Pediatr. 2021;21(1):372. 10.1186/s12887-021-02845-3 . PMID: 34465285; PMCID: PMC8406827. Wenwen Y, Tiantian G, Jing Z, et al. A case of Brucella endocarditis with concurrent epididymitis and splenic infarction [J]. Chin J Infections Chemother. 2019;19(03):319–22. Brichacek M, Blake P, Kao R. Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report. BMC Res Notes. 2012;5:695. 10.1186/1756-0500-5-695 . PMID: 23267527; PMCID: PMC3583747. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Oct, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 19 Sep, 2024 Reviews received at journal 17 Sep, 2024 Reviewers agreed at journal 07 Sep, 2024 Reviews received at journal 08 Jul, 2024 Reviewers agreed at journal 04 Jul, 2024 Reviews received at journal 26 Jun, 2024 Reviewers agreed at journal 23 Jun, 2024 Reviewers agreed at journal 21 Jun, 2024 Reviewers invited by journal 21 Jun, 2024 Editor invited by journal 20 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 14 Jun, 2024 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. 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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-4583183","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":324361152,"identity":"111835b5-58d7-4b69-9488-c99d7140b2c7","order_by":0,"name":"Zhao Yu","email":"","orcid":"","institution":"Haining People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhao","middleName":"","lastName":"Yu","suffix":""},{"id":324361154,"identity":"dcaa66d7-8fd6-452f-9aa9-461fed0be4bb","order_by":1,"name":"Yuanyuan Qian","email":"","orcid":"","institution":"Haining People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Qian","suffix":""},{"id":324361158,"identity":"0c8e1d87-cf82-4d29-ab8c-26914bb56161","order_by":2,"name":"Lan Lv","email":"","orcid":"","institution":"Haining People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lan","middleName":"","lastName":"Lv","suffix":""},{"id":324361163,"identity":"685a2bbe-3482-4da7-81b9-b2f515438df7","order_by":3,"name":"Wenqing Hu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYBAC+/bmAwc+VPyv7ydaiwHPscSHM84wM85sIFqLRI6yMWcbM+OGA8RqMWfIYZNmbGNjNj6evIHhR8U2wlosG84eky44x8NmduZZAWPPmdtEWHOwL016RpkEj9mNHANmxjZitBzmMZPmYTOQMJ5BrBaDYzzGxjxtCQbAcCBSi2QPGyiQDyRIAP1ykCi/8Ms/BkXlgQT+9uSND35UEOMXBEgwOECSerAWUnWMglEwCkbBCAEAoyNAcuTLxW8AAAAASUVORK5CYII=","orcid":"","institution":"Haining People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wenqing","middleName":"","lastName":"Hu","suffix":""}],"badges":[],"createdAt":"2024-06-14 16:06:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4583183/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4583183/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-024-10111-x","type":"published","date":"2024-10-25T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60602283,"identity":"cec720aa-4f30-498e-9f60-3a68eb2089b8","added_by":"auto","created_at":"2024-07-18 16:12:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":67701,"visible":true,"origin":"","legend":"\u003cp\u003eChest and upper abdominal CT upon admission on June 4, 2023: Inflammation of the upper and lower lobes of the right lung with partial consolidation, multiple cysts within the liver, with the remainder of the abdominal CT scan showing no abnormalities.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4583183/v1/1c9572338029d57c9d662d73.jpg"},{"id":60601092,"identity":"1cdb7f96-673d-493c-9825-d84da6995b7f","added_by":"auto","created_at":"2024-07-18 16:04:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67026,"visible":true,"origin":"","legend":"\u003cp\u003eEnhanced abdominal CT on June 12, 2023: Gerota's fascia effusion, splenic infarction, and abdominal pelvic effusion.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4583183/v1/2743198b9368342eb9be032a.jpg"},{"id":60601091,"identity":"c9dae460-b16c-4a00-a273-f36790e3209f","added_by":"auto","created_at":"2024-07-18 16:04:05","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":124038,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT on July 26, 2023: Inflammation in both lungs, a small amount of pleural effusion on both sides, slightly absorbed compared to the previous image (July 14, 2023). Mild enlargement of mediastinal lymph nodes, coronary calcification, with noted: low-density lesions in the spleen.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4583183/v1/42f0c6154621e9f1c97dec4a.jpg"},{"id":60602945,"identity":"f49bb982-8bae-49ba-b143-cf984cb503bc","added_by":"auto","created_at":"2024-07-18 16:20:05","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":79698,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment, changes in medical condition, and post-discharge follow-up during the hospital stay from June 4, 2023, to July 26, 2023.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4583183/v1/048826443831a7d9a9f5ea7d.jpg"},{"id":67682303,"identity":"14713f88-74d1-44d5-8ed2-98e744c6d9a2","added_by":"auto","created_at":"2024-10-28 16:13:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":567877,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4583183/v1/23628060-7c79-4c8a-b13d-57f9f47f4e3a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Case of Severe Psittacosis Pneumonia Complicated by Splenic Infarction","fulltext":[{"header":"Clinical Data","content":"\u003cp\u003eThe patient, a 76-year-old female, was admitted to the hospital on June 4, 2023, presenting with a three-day history of fever and cough, which escalated to somnolence on the day prior to admission. Initially, she exhibited a fever peaking at 39\u0026deg;C and a paroxysmal dry cough without diurnal variation. Her condition deteriorated the following day, marked by altered consciousness and hypotension, with blood pressure dropping to 70/46 mmHg (1 mmHg\u0026thinsp;=\u0026thinsp;1.33 kPa). She received interventions to elevate her blood pressure, alongside anti-infective treatment and fluid resuscitation. Her medical history included hypertension, but she denied any history of diabetes, atrial fibrillation, or cardiac valvular disease. Her occupational background in agriculture involved prolonged exposure to domestic poultry, and she reported no smoking or alcohol consumption. Physical examination: Respiratory rate: 22 breaths/min, heart rate: 81 beats/min, blood pressure: 121/77mmHg (Norepinephrine 10mg, 0.37ug/kg/min). Coarse breath sounds and scattered wet rales were noted in both lungs, while cardiac examination revealed a regular rhythm without significant arrhythmias or murmurs. The abdomen was distended without tenderness or rebound pain, and no obvious hepatosplenomegaly was palpable.\u003c/p\u003e \u003cp\u003ePost-admission Comprehensive Examination: On 2023-06-04 (DAY1), arterial blood gas analysis showed pH of 7.37, PCO2 of 34.0 mmHg, PO2 of 78.0 mmHg under mask oxygenation, and an oxygen saturation of 95%. Emergency complete blood count and inflammatory markers showed a white blood cell count of 12.4\u0026times;109/L, with a neutrophil percentage of 95.9% and lymphocyte percentage of 2.6%. The platelet count was 220\u0026times;109/L, and high-sensitivity C-reactive protein (CRP) exceeded 370.0mg/L. Coagulation tests revealed a prothrombin time of 9.3 seconds, plasma fibrinogen of 9.22g/L, and D-dimer of 2.278\u0026micro;g/mL. Procalcitonin (PCT) and interleukin-6 (IL-6) levels were 9.58 ng/mL and 1391.1 pg/ml, respectively, while the nucleic acid test for the novel coronavirus returned negative. Chest and abdominal CT scans on the same day revealed pulmonary infection, with inflammation and partial consolidation in the upper and lower lobes of the right lung (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUpon admission, the patient's evaluations included: a Sequential Organ Failure Assessment (SOFA score) of 8 points; a CURB-65 score for community-acquired pneumonia of 3 points; a Pneumonia Severity Index (PSI) of 149 points, classifying as class V ,with a predicted mortality rate of 27%; and a Venous Thromboembolism (VTE) score - Padua Prediction Score of 6 points, indicating a high risk.\u003c/p\u003e \u003cp\u003eTreatment: On the admission day (June 4, 2023), the patient, experiencing a reduction in oxygenation, was promptly intubated and placed on mechanical ventilation. Imipenem/cilastatin 0.5g every 8 hours combined with tigecycline 50mg every 12 hours was administered for anti-infection, along with enoxaparin 0.2 ml subcutaneously every 12 hours for anticoagulation, and treatments for expectoration and asthma relief. On June 7, 2023 (DAY 3), bronchoscopy was performed, and the lavage fluid was analyzed using mNGS at Zhejiang Shengting Medical Laboratory Co., Ltd., identifying a Chlamydia psittaci infection with 5434 sequence counts, with no viral RNA sequences detected the following day (June 8, 2023, DAY 4). Treatment was adjusted to moxifloxacin sodium chloride injection 0.4g daily with continued tigecycline 50mg every 12 hours for anti-infection, complemented by intermittent prone positioning ventilation and bronchoscopy suction among other supportive care measures. Subsequent treatment led to improvements in pulmonary function, enhanced oxygenation, and reduced inflammatory markers such as PCT and CRP. On June 12, 2023 (DAY 8), the patient reported concealed pain in the upper left abdomen with palpation tenderness but no muscle tension. Blood tests showed hemoglobin at 74 g/L, platelets at 60\u0026times;109/L, fibrinogen at 0.64 g/L, and D-dimer at 35.682 \u0026micro;g/ml; an enhanced abdominal CT scan revealed Gerota's fascia effusion, splenic infarction, and abdominal pelvic effusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFollowing discussions at a Multi-Disciplinary Treatment (MDT) meeting, the patient was diagnosed with severe Psittacosis pneumonia complicated by splenic infarction. Given the absence of splenic abscess or rupture and no need for surgical intervention, conservative medical management was employed. Enoxaparin injections were substituted with rivaroxaban 10mg administered nasogastrically once daily for anticoagulation, complemented by supportive treatments including transfusions of fibrinogen, platelets, red blood cells, plasma, and cryoprecipitate. Subsequent to these interventions, the patient's abdominal pain subsided, inflammatory markers diminished, and oxygenation levels increased. Mechanical ventilation was ceased on June 16, 2023 (DAY 12), and the patient was transitioned to a regular ward with high-flow nasal oxygen. Post-discharge imaging revealed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) substantial resolution of pulmonary inflammatory lesions and improvement in the spleen's low-density lesions compared to prior assessments. The therapeutic approach during the hospital stay, evolution of the patient's condition, and discharge follow-up findings are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis study received approval from the Ethics Committee of Haining People's Hospital [Approval number: (2023) Ethics Review No. 118], and informed consent was duly obtained.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePsittacosis, caused by Chlamydia psittaci of the Chlamydiaceae family, is an obligate intracellular parasite with 17 identified genotypes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Transmission occurs through direct contact with infected birds, poultry, mammals, their feces, respiratory secretions, or contaminated aerosols. Psittacosis pneumonia represents about 1.03% of all community-acquired pneumonia cases worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], with epidemiological data from 21 countries across all continents indicating positivity rates between 0.34% and 93.8%. In China, reports have emerged from 16 provinces [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Clinically, symptoms range from asymptomatic to typical respiratory infection signs, with severe cases necessitating mechanical ventilation and intensive care. Radiographic findings include patchy consolidations or ground-glass opacities, bronchiectasis, and uni- or bilateral lung involvement. Severe instances often exhibit bronchial inflation, correlating with disease severity. Although blood tests like white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) can indicate anomalies, their lack of specificity contributes to frequent misdiagnoses or overlooked diagnoses with standard imaging and blood tests [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Definitive diagnosis hinges on isolating Chlamydia psittaci from respiratory or blood samples, but traditional culturing methods are slow, hindering timely diagnosis. However, recent adoption of metagenomic next-generation sequencing (mNGS) in infectious disease diagnosis enables rapid, untargeted sample testing within approximately 24 hours [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], facilitating swift antimicrobial treatment adjustments and enhancing treatment efficacy. Tetracyclines are typically the first-line treatment, with macrolides or fluoroquinolones as alternatives if tetracyclines are unsuitable [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Current research indicates that the psittacosis pathogen is sensitive to both quinolones and tetracyclines, with a high cure rate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSplenic infarction (SI) is characterized by ischemic necrosis of the spleen due to obstruction of the splenic artery or its branches, potentially leading to serious complications such as splenic abscess, secondary infection, and significant hemorrhagic splenic rupture, posing a critical risk to patient survival. Clinically, it manifests as upper left abdominal pain, fever, chills, and nausea, though asymptomatic presentations are possible, increasing the risk of misdiagnosis or delayed diagnosis. In some instances, a definitive diagnosis is only achieved post-mortem via autopsy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The literature has identified leukocytosis, lymphopenia, prolonged activated partial thromboplastin time, decreased fibrinogen, liver dysfunction, elevated LDH, and blood urea nitrogen as positive indicators of splenic infarction, serving as predictive factors for patient prognosis [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Several factors can cause splenic infarction: 1) Vascular diseases of the spleen due to the end-arterial nature of splenic artery branches, predisposing them to thrombosis from atherosclerosis, bending, or reduced blood flow with age; 2) Hypercoagulable states, such as those associated with pancreatic cancer or malignant lymphoma, which can induce thrombosis and subsequent infarction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; 3) Cardiac diseases like infective endocarditis, atrial fibrillation, and rheumatic heart disease can lead to cardiac valvular vegetations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; 4) Iatrogenic causes during vascular interventional procedures can lead to embolic agents inadvertently entering the splenic artery, causing ectopic embolisms [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this case, despite anticoagulation prophylaxis during the treatment of confirmed psittacosis pneumonia, splenic infarction still occurred. The patient had no tumors, cardiac disease, or underlying hematological conditions, and ultrasound did not reveal portal vein system thrombosis or cardiac valvular vegetations, suggesting none of the aforementioned causes.\u003c/p\u003e \u003cp\u003eRecent years have seen an uptick in case reports of splenic infarction associated with infections, as documented in both domestic and international literature. Researchers such as Childer, Hahn, and Yin Wenwen [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] have reported rare instances of splenic infarction linked to infections like COVID-19, Mycoplasma pneumoniae, and Brucella. However, reports of splenic infarction due to Chlamydia psittaci infection are nonexistent. Splenic infarctions related to severe infections are infrequently cited in clinical cases, with their underlying mechanisms still to be elucidated. One possible explanation is the formation of in-situ bacterial thrombi in the splenic artery caused by severe infections or thrombosis formation in a hypercoagulable state due to septic shock, which blocks the splenic artery. Additionally, infections can lead to endothelial dysfunction of vascular cells, triggering fibrin formation and platelet adhesion and aggregation, ultimately causing splenic artery thrombosis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Further, evidence indicates that the interplay between coagulation pathways and the complement cascade in Mycoplasma pneumoniae infections could lead to infarctions across various anatomical sites [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Given that Chlamydia and Mycoplasma are atypical pathogens, the similarity of their thrombotic mechanisms in infections warrants additional investigation.\u003c/p\u003e \u003cp\u003eThis case marks the inaugural report of severe psittacosis pneumonia with concurrent splenic infarction. A review highlights the need to be vigilant for rare complications such as splenic infarction in severe cases of psittacosis pneumonia. Patients on mechanical ventilation, especially in sedated states, should not overlook changes in abdominal signs and vital signs. The detection of decreased fibrinogen and platelets, elevated D-dimer, and fluctuations in inflammatory markers, coagulation functions, and hematologic lab parameters should raise alerts for potential thrombotic or hemorrhagic occurrences. The causative link between severe psittacosis pneumonia and subsequent splenic infarction merits deeper investigative scrutiny.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of \u0026nbsp;Haining People\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the Ethics Committee of Haining People\u0026apos;s Hospital [Approval number: (2023) Ethics Review No. 118].Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors\u0026nbsp;report no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors listed in this article have made significant contributions to the work of the report. ZY is responsible for collecting medical records and writing papers；YYQ is responsible for collecting medical record data and processing images and tables；LL is responsible for literature search and organization；WQH is responsible for literature screening and guiding paper writing.All authors participated in drafting or writing, or substantially revised or critically reviewed the article, and have agreed on the journal in which the article will be submitted. Finally, all authors agree to take responsibility and be accountable for the contents of the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHogerwerf L, DE Gier B, Baan B, et al. Chlamydia psittaci (psittacosis) as a cause of community-acquired pneumonia: a systematic review and meta-analysis. 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Multiple anatomic sites of infarction in a pediatric patient with M. pneumoniae infection, a case report. BMC Pediatr. 2021;21(1):372. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12887-021-02845-3\u003c/span\u003e\u003cspan address=\"10.1186/s12887-021-02845-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34465285; PMCID: PMC8406827.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWenwen Y, Tiantian G, Jing Z, et al. A case of Brucella endocarditis with concurrent epididymitis and splenic infarction [J]. Chin J Infections Chemother. 2019;19(03):319\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrichacek M, Blake P, Kao R. Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report. BMC Res Notes. 2012;5:695. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1756-0500-5-695\u003c/span\u003e\u003cspan address=\"10.1186/1756-0500-5-695\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 23267527; PMCID: PMC3583747.\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":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"psittacosis, splenic infarction, critical pneumonia.","lastPublishedDoi":"10.21203/rs.3.rs-4583183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4583183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePsittacosis pneumonia, a zoonotic infectious disease transmitted from birds to humans, is caused by Chlamydia psittaci and represents a type of chlamydial pneumonia [1]. In severe instances, the disease may progress to critical pneumonia and respiratory failure, necessitating intensive support measures, including mechanical ventilation. The advent of technologies such as Metagenomic Next-Generation Sequencing (mNGS) for the etiological diagnosis of infectious diseases [2] has enhanced the diagnostic and treatment success rates for Psittacosis. Instances of severe chlamydial pneumonia with complications such as splenic infarction are uncommon. A patient with severe Psittacosis pneumonia complicated by splenic infarction was admitted to the Emergency Intensive Care Unit (EICU) of Haining People's Hospital and subsequently improved following effective anti-infective and anticoagulant therapy. This report and share are as follows.\u003c/p\u003e","manuscriptTitle":"A Case of Severe Psittacosis Pneumonia Complicated by Splenic Infarction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 16:04:00","doi":"10.21203/rs.3.rs-4583183/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-19T06:20:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T15:39:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330541571568810618731040094627324299159","date":"2024-09-07T14:05:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-08T19:48:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329276959822994100026567567873922956356","date":"2024-07-04T15:02:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-26T15:12:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30756435695239981722802044069817289115","date":"2024-06-23T15:55:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78420079252394971538651802371014514028","date":"2024-06-21T10:25:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-21T09:33:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-20T05:25:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-20T00:24:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-20T00:24:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-06-14T16:05:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7b5c0ca-b7e5-4f39-8fa3-2d68a928d94d","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:08:09+00:00","versionOfRecord":{"articleIdentity":"rs-4583183","link":"https://doi.org/10.1186/s12879-024-10111-x","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-10-25 15:57:37","publishedOnDateReadable":"October 25th, 2024"},"versionCreatedAt":"2024-07-18 16:04:00","video":"","vorDoi":"10.1186/s12879-024-10111-x","vorDoiUrl":"https://doi.org/10.1186/s12879-024-10111-x","workflowStages":[]},"version":"v1","identity":"rs-4583183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4583183","identity":"rs-4583183","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}