Multisystem Thromboembolic Shower in the Intensive Care Unit: Acute Limb Ischemia and Mesenteric Embolism.

BACKGROUND

Acute limb ischemia is a catastrophic vascular emergency that can easily be obscured by the physiological noise of septic shock and mechanical ventilation within the intensive care unit.

CASE SUMMARY: A 75-year-old Caucasian woman presented to the emergency department and was subsequently admitted to the intensive care unit with acute hypoxic respiratory failure and severe septic shock secondary to a primary lobar bacterial pneumonia. She was obtunded, tachycardic, and hypotensive upon arrival. She experienced a transient 4-hour paroxysm of new-onset atrial fibrillation. Targeted physical examination revealed a profoundly cold right lower extremity with absent peripheral pulses. Emergent computed tomography angiography revealed a complex, multisystem macrovascular catastrophe: an acute superior mesenteric artery occlusion alongside a 15-mm right common iliac artery thrombus causing near-subtotal occlusion. Prompt systemic anticoagulation and surgical thrombectomy successfully preserved bowel viability and avoided a major lower limb amputation.

DISCUSSION: Widespread multibed embolic showers require high clinical suspicion when brief tachyarrhythmias interact with the hypercoagulable cascade of systemic sepsis.

TAKE-HOME MESSAGE: Systematic peripheral vascular assessments are vital in complex sepsis presentations to prevent devastating diagnostic delays.