#mod septic

[homestuck--edits]

hiii. i was wondering if you could edit the shoosh papping scene (page 4091) with crockertier Jane as Gamzee and Roxy (preferably in her god tier outfit, but whatever is easiest for you lol.) as karkat consoling her. cheers!

yes :>

-mod davesprite

[pronoun-shop]

hello hello! this is a long ask, sorry!!!

can I get a name + prns check? I go by multiple names, so I hope this won't be a problem :,)

names

corpse

dionysus

adele

pronouns

they/them/theirs

septi/septic/septicself

oto/otona/otonaself

🫀/🫀's/🫀self

(could you do a paragraph for each name, all of them using the all the prns if that makes sense) ((you don't have to if it's too much))

Of course! Sorry this one took a while 😅

Corpse, 🫀/they/septi/oto

This is corpse, have you met 🫀 before? They live in my neighborhood, otona lives across the street from me. Yeah, we went to the same elementary! Bookboss elementary! Septi had a different math than me, but other than that, we had all the same classes!

Dionysus 🫀/they/septi/oto

This is Dionysus, have you met them before? They’re really cool, our parents are friends. I loveee 🫀 room, septi has it really well decorated. Otoan room also has a room access, so septi also have a mini fort up there! I’ll ask 🫀 to send some photos, you gotta see it.

Adele 🫀/they/septi/oto

Oh hey! Nice to see you! Huh? You’re looking for Adele? I think I know where they are, last I saw septic was in the art class, 133. If 🫀 isn’t there, oto might be outside on the playground, with void and noe. I don’t know where else they could be, but you could always ask lass, xe might know. Good luck!

[yourtongzhihazel]

I've been thinking about getting Workers and Resources but have a two questions about it:

1. how low can you get those graphics to increase performance? my laptop is NOT built for gaming but I crave a planned economy simulator

2. does it have similar issues to cities skylines? either in terms of bugginess or gameplay plateauing and getting boring

thx so much :)

1: I do have a gaming laptop but to reduce its operation to about the same as a standard consumer laptop, I run 4 firefox windows each with 30 tabs and also have MATLAB constantly running. This eats about 80% of its functional ram and CPU/GPU power. Despite this sadist torture of my beloved silicon sister, she can still run W&R:SR adequately with their lowest auto settings. The game runs on unity (afaik) so you can customize most of the major things in the initial startup menu.

2: In my humble opinion, W&R:SR is in a completely different league to any other city builder. I would argue that it is the quintessential economy management sim.

It is a a slow game. It challenges your patience as much as it does your planning, management, and calculation skills. Expect to have the calculator open on your phone on in another window when playing and a notepad for tracking required manpower and economic consumption vs output. Does the game get boring? I would say sometimes it does! Waiting for an entire city to build up by itself can take several hours on maximum time speedup, which may or may not be your cup of tea.

Comparing W&R:SR to city skylines is like comparing a construction site to a lego set.

Sim management is about as specific as you can go without controlling each individual citizen. Command your citizens to go to specific buildings to work or wait for transit. Command your citizens to go to which stations or buildings for work or for play or for education, etc..

The biggest example of difference I like to use is the water management. In cities skylines, you drop a sewage dump, and a well then you connect magical underground pipes and call it a day. This will not work in W&R:SR. Water must reach a certain quality of treatment of your citizens will get sick. You have to power these facilities and also take sewage out from them. Water must be supplied to every building which workers work. Sewers must run on a downwards slope and pumps must be built if there is an unfortunate slope. Sewage can be treated to reduce pollution or to return some fresh water back into the system. Some factories, such as the concrete plant, requires water as a resource. If you cannot afford pipes or do not want to run pipes down to some stupid wood-cutting shack, you can use the water distributor/sewage hub as a water tank/septic tank and have your maintenance depots take care of them.

This doesn't even touch on having to supply heat and clear snow during winter, having enough granaries to survive the winter when crops don't grow, managing the waste, demolition, and recycling of materials, maintaining your aging vehicles with repair shops and supplying fuel for all your cars, trucks, planes, ships, trains, and buses, and much, much more.

Oh and there is a very vibrant modding scene; the devs even hold contests/votes to put popular mods into the vanilla game (with compensation and credit, ofc). It's also the only game where you can get tankie memes in the community page and actual propaganda.

It's a very dense game, to say the least, and it kicks my ass a lot but im too much of a commie and a masochist to say no.

[slocumjoe]

I don't know if you do romances companion requests but if you doooo.....

Could you do ram Lance's companions reacting to a sole with tattoos getting their name as a tattoo?

I...didn't realize it was a typo, and googled 'ram lance fallout 4 companion mod'...

I've said this before, but I'm solidly in the camp of "this is the final groan before it all collapses" in regards to getting tattoos for/with your s/o...so, maybe a little biased here

Cait; Unhealthy relationships + Sole is the only person who's ever treated her decently = she's the type to enjoy this. That sounds incredibly brusque and cold, but c'mon. Have you heard a romanced Cait? Girl is over the moon obsessed, has nothing but schmoopy heart eyes. Sole letting everyone know fuck you, I'm hers, they can expect Cait to cash that metaphorical check in. Immediately gets Sole's name tattooed as well.

Curie; ...it's a sweet sentiment, but...how positive were they, that the equipment used was clean and the artist reputable? Curie is a hygiene freak. Tattoos, even without the liability of being in a rusty, dusty apocalypse, can get pretty fucking gnarly. They need constant maintenance and care during the healing process, and infections can kill. Septic shock is nothing to wave off. She'll think its sweet for maybe three seconds before panicking.

Danse; Exactly like Curie. Very sweet, speaks to their devotion to him and them (as a couple), and then squints. Hey, love of my life? You got that professionally, right? Outstanding, outstanding...but what does 'professional' mean in a wasteland? Didn't realize tattoos bleed, so the first time that happens, straight to the most reputable doctor (Curie), completely convinced Sole is dying because of him.

Deacon; Not into it. Not even a little. They're spies, presumably. Having a big identifying mark on your body? Bad. Having a big mark on your body that identifies Deacon? Worse! They may as well have gotten a tattoo of his face, age, weight, and height on a wanted poster, are you kidding? Sure, cover it up, maybe, but its still there. There's still an artist somewhere who knows what Sole looks like, knows what tattoo they asked for, probably knows who it refers to. This isn't even getting into the commitment and vulnerability part, that's a whole other thing. But no, Deacon is actually rather horrified.

Gage; The same as Deacon, but less about commitment. If you've got Gage, you've fucking got him. It's the information of it. Sole is putting a weakness on a silver platter for anyone to take advantage of—displaying that Gage is something close to them, something that matters, and vise verse. Raiders are fucking vultures, they'll use that. Gage will offer to get matching tattoos that are undetectable as matching tattoos, something that a third party wouldn't know were half of a set. Like...Sole gets an evil eye, referencing Gage's situation Up There, Gage gets moving gears for Sole's status as a Vault Dweller. Shit like that.

Hancock; Into it as well, no drawbacks. Well, there is one, if Sole tattooed Hancock and not John. If they got Hancock, is a little weirded out that they got the name of a historical figure tattooed on them, that's kinda odd to him. Yeah, it's referring to him, but Hancock is only Hancock because he's trying to be–...John...Hancock...wait, so even John isn't...he's...

Has a mild identity crisis.

MacCready; He's 22. Yes he's into it. Yes I say this with derogatory intent. MacCready might not be okay with needles himself, but he thinks its cool that Sole is. And got his name done. That's...that's a solid way to commit, huh? He's more likely to carved their name into his gun than go under a needle that isn't a stimpak, but appreciates the thought.

Nick; He's an older man. This is the kind of thing that most people age out of, and Nick is one such person. Tried to get a tattoo for a guy he was sweet on in High School, at least, OG Nick did. Couldn't, being 15, but the tattoo artist didn't just turn him away, she explained why it wasn't a good idea. That stuck. Now, with Sole...he's more open to it. It's Sole, his partner in crime-fighting, someone he trusts deeply. They want to express their love for him like that, sure. He thinks its kinda crazy, but hey, this is the same person who tries to have sex with a robot with no dick, tongue, and barely touchable hands.

Piper; Piper knows all the tea, everywhere, all the time. She probably knows many people who've done this, only for the relationship to implode. So...Sole shows her, and Piper grins real big, says its sweet, immediately wants to have a Deep Discussion about their relationship. Did someone tell you this was a good idea? She likes it, very sweet, but seriously, this is the first cut of a thousand. It's possible to win her over, Sole just needs to reassure her that it was genuinely out of affection and commitment, not...like, getting out of the doghouse, or whatever.

Preston; Is neutral to it. He doesn't have the Dark Knowledge that people like Nick and Piper do, but he also wasn't ever...worried, I guess? Preston didn't need a sign like that. It's a take it or leave it thing. He thinks it's sweet, but it's not like he would have been worried if they didn't/wouldn't have gotten it. Also down for matching tattoos, though. Those tattoos wouldn't be as discreet like with Gage, far more uniform and clearly a pair. Maybe one of them gets the rifle from the Minutemen logo, and the other gets the sword?

X6-88; Coursers canonically have 'synth' tattooed in binary on their neck, so it isn't a stretch to think they also just have their...names? Labels? Tattooed as well. So, he's entirely confused as to why Sole tattooed his name on them. That's...his name. And it's not even in the right place, it goes on the collarbone...why did you do this? As a romantic gesture? Getting the same tattoo as your partner a sign of affection, then? But...his is his designation...wouldn't it have made more sense for Sole to get their own name tattooed on themselves?

[real-total-drama-takes]

Mod Courtney I am so sorry for the shitting discourse, none of us will be seeing heaven

What’s worse is that it’s blatantly wrong.

There are communal bathrooms in total drama island, and it’s confirmed that there’s toilets in there. Like, many times. Duncan falls asleep in one in the awake-a-thon episode. Harold is ambushed after leaving a stall in the fear factor episode. Gwen has to drink from the toilet in one of the stalls in the triple dog dare episode (These are all off the top of my head)

BUT. And this is important. It is ALSO confirmed that the confessional outhouse is used as a toilet in some cases. Lindsay pees in it on camera in the first episode (and also in the intro). Owen shits in it while he’s handcuffed to heather, and then again in the finale episode (I think?) but in those cases he’s got like, explosive diarrhea for whatever reason. The confessional outhouse IS a bathroom and CAN be used as one (and occasionally is a sort of last resort), but it typically ISN’T because no one wants to be seen pooping on camera. In Lindsay’s case when she noticed the camera she got embarrassed.

However. HOWEVER. Based on TDI (2023) it does seem like there are no more communal bathrooms, which is weird because they were still on the island as of TDROTI (the interns had to empty the sewage septic tank). I believe this because of the dialog surrounding MK’s spying strategy and also because they didn’t have any instances of the characters in the communal bathrooms like they have in other seasons. It does seem like a weird retcon and I have no idea why they did it. EITHER THAT OR everyone on TDI 2023 just collectively decided that they didn’t give a fuck about social convention and decided they were all gonna shit in the confessional camera.

Briefly mentioning the other seasons—

TDA - there’s not even a toilet in the confessional dressing room. They have other bathrooms.

TDWT - planes almost always have 2-4 bathrooms. They have other bathrooms.

TDROTI - communal bathrooms are (still) on the island. They have other bathrooms.

TDPI - this one I’m at a complete loss. I can’t remember if they confirmed one way or the other

So yeah, that’s my opinion on it. This is way too long and I’m sorry to anyone who read this whole thing lol

[killed-by-choice]

“Chelsea Roe” 36 (September 7, 2022)

An unidentified healthcare professional reported the horrific death of a woman who underwent a chemical abortion with RU-486 and misoprostol. “Chelsea” is still unidentified, but her case is documented in a FAERS report.

Chelsea underwent a “safe and legal” chemical abortion. She suffered from necrotizing fasciitis, literally rotting from the inside while she was still alive. She also suffered from septic shock and MODS (Multiple Organ Dysfunction Syndrome). Her death was likely excruciating. She died on September 7, 2022 at the age of 36. She and her baby both suffered a needless death.

Even though Chelsea was killed in September of 2022, the FDA did not receive any reports of her death for almost six months. On February 3 of 2023, the FDA finally received a report of her case.

The report did not specify the country where Chelsea was killed, but since the case was reported to an American government agency, she was likely killed in America.

It is unknown if the manufacturers of the abortion pill were ever informed of what their toxic product did to Chelsea.

FAERS Case 21949658

[fazbears-horror-attraction]

[ID: There are four flags, with one and three having Jack Septic Eye, and two and four having no picture of him. The flags have seven stripes and the colors are black, dark green, medium green, blue medium blue and cyan. End of ID]

Neopronoun's flags are on the top, mine are on the bottom.

★ FactiviJackSepticEye -> A gender relating to being a factive of Jacksepticeye.

Made for: No One Creaton

Tagging: @pluralterms @radiomogai

date: 1 / 9 / 2024

Note: Anyone can use my ( Mod Phantom ) terms. If you are on our DNI you can still use them, but please do not interact with our blog ( You may re-upload my flags to your hoard as long as you credit me, that is all i ask as i am aware of death of an author. You may also redesign my flags, but please credit and/or tag me. Thank you )

[fruitcakebro]

Can't post on Reddit right now, bc mod strike solidarity. But this would normally go on R/MaliciousCompliance.

So, my family moved into our current house about four years ago now. When we first saw it, it immediately jumped out at us as perfect. It had a number of bedrooms where nobody would have to share, but not so much space that it would be impossible to clean. Nice view, garden space, seemingly all you could want.

We bought the house, but not a week after we had moved in there started to be some pretty glaring problems.

1: The water heater didn't work, and we had to have it repaired.

2: Water leakage which was damaging the structure of the house, and causing black slime mould in the walls.

3: Some weird shit going on with lights that only sometimes worked (we saw the house in person, but only in full daylight where this would not be obvious).

4: A septic tank they hadn't had serviced in five fucking years.

5(And this was perhaps the most immediately relevant to us at the time): The heat didn't work. And we moved in at the start of winter.

And of course, we had not been informed of any of these things when we bought it. We were told that everything was fine, and they'd literally JUST gotten some things fixed to sell it. Nevermind that those 'repairs' were as slap-dash as they could possibly be done.

Based on this, I expect you get the impression that we absolutely fucking despise the family that lived in our house before us.

And on top of everything, they didn't even fix their mailing address, so we still got their mail. And after calling them about it, and re-directing their mail for an entire bloody year, we were told to 'just stop bothering them about it'.

You want us to stop telling you when we get your mail? Well ok then.

Shortly after we were told that, we received one of their phone bills, and since we were told not to, we politely did not tell them about it.

We're still getting overdue notices on it, and we get to watch in smug, petty, spiteful joy as their credit score is slowly but surely destroyed by a piece of paper they told us not to tell them about.

Fuck you, lying jackasses. Here's the sweet, sweet consequences of your actions.

[meo618]

The Ego Fandoms are dead. Mark basically killed any and all shipping after Heist by telling people his Egos stories didn't matter in the long run as it was only what he was telling us currently that was important.

Jacksepticeye"s Egos got done dirty by Sean for so long people forgot about them. His Mods on his Discord are his Ecco chamber and reassure him everyone still loves and obsesses over Anti. But honestly no one gives a shit anymore. He liked about doing something with them for years and then passed it off to one of his Fans he hired to write the story for him.

And Sanders Sides has been pushed away by Thomas being a Money hungry asshole And just collected fat Patreon checks while pushing Merch disguised as content. All Ego Fandoms are dead.

💀🪦⚰️

..I've barely interacted with the septic egos or Sanders Sides, I have no idea why you are bringing this into my inbox.

Great and all that you have your personal opinion but shouting all this at a stranger is a bit unbecoming? I asked why a particular ship has become so rare, not about how shit the fandoms/creators are.

I'm having my fun with Marks egos, and so do a decent amount of other people as far as I can tell.

Please at least ask beforehand.

[hideneverseek]

I can't handle people that shit on DIY body mods arguing that a professional piercer or tattoo artist will "actually know what they're doing" and there's less risk of infection or something?

Like I sterilize my area, supplies, and jewlery before I do any mods and I've been doing my own and other people's mods for years now. It's free or at most I'll charge a friend $30 for whatever (my lucky bastard partner gets everything for free lmfao). I'm clear about my level of experience, don't promise anything I can't do, and I've never had an issue with infection or bodily rejection of a piercing.

Anyway, long rant short, these weird snobs can throw away thousands of dollars on body mods when I have months of supplies for myself and friends for like $60 I guess.

"go 2 professional!!!!! U don't know what ur doing!!!!!!"

Guess I'm gonna wake up one day and my 14 self done piercings and 14 self done tattoos that have all healed perfectly will go septic and I'll just die in bed because I didn't specifically go to a professional, same for anyone I've ever done body mods on, and gave a haircut to or something cause I'm not a professional hair stylist either. Better stop playing video games because I dont have 59 PS5's to run it on for the processing power they use for trailers and premiers and shit. Better quit working as a cook because I don't have a culinary degree, I only got the job because I know how to handle food, but fuck I guess I'm not a "professional professional"

[z-raven]

Saints Row 2

Lately, I been playing a lot of Saints Row 2, feels good to get back into a game that I really love playing.

I finished the game multiple times in the past and it is usually a good time, except some of the activities I don't really enjoy doing such as Mayhem, Insurance Fraud, Heli Assault, Fight Club, and Crowd Control.

Some of the activities were better in the sequels, like Heli Assault for example is better in SR3 over SR2, because in SR2 the Helicopter can go crashing down way too easily by the slightest bump into something or a missile hitting it.

I never really found Mayhem and Insurance Fraud in any of the SR games to be fun imo, because it comes down to whether or not things spawn that you can get points off of.

It does disappoint me that Demolition Derby and Septic Avenger never appeared after SR2, those were 2 activities I really enjoyed.

I don't really care for getting 100% completion, I just tend to unlock the things I really find worth getting.

Also since I am playing on PC some of the stuff controls just worse imo

I know the Gentlemen of the Row mod fixes a lot of the issues such as actually telling you what button to press on a 360 controller to perform certain actions, but in my experience the mod makes the game less stable and more prone to crashing and that makes me not use it.

[uvzbfine]

Critical Care Nursing Made Incredibly Easy - David W. Woodruff

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Feeling unsure about your critical care nursing skills? Time to gain some confident know-how, with the freshly updated?Critical Care Nursing?Made Incredibly Easy!?, 5th Edition. ? This friendly, fully illustrated guide offers clear, concise direction on treating numerous acute and life-threatening issues. Absorb current best practices on critical care basics and specialized areas such as advanced life support measures, multisystem trauma, and treating specialized needs. This is ideal guidance for students, nurses new to clinical care, and those preparing for the Critical Care (CCRN) certification exam. ?Let this expert review text guide you to exam and on-the-unit success: NEW ?end-of-book practice examExpansive, systems-based review of acute care conditions?for all body systemsGuidance on treating multisystem disorders?? burns, hyperthermia, hypothermia, hypovolemic shock, multiple organ dysfunction syndrome (MODS), septic shock, trauma and moreExpert guidance on nursing skills??

[sidsaysthings]

The picture was taken without permission... so I covered the face. By the side of loved ones, praying to Allah in the hope of easing the pain of death…. This patient is 38 years old. Neutropenic sepsis, septic shock, MODS & DIC. All efforts failed. We have nothing else to do. She might die after a while. After coming on night duty, I called the patient's husband and gave negative counseling. I said you can stay next to the patient if you want. After 1 hour rounds, I saw him crying and praying in his mind. I went a little earlier and saw that he was still praying. What a pain… what a pain…. Think once... How would it feel? You know your loved one will die after a while? You have nothing to do. How much to say!!! How much work was left!! Maybe a new house was supposed to be bought!!! Maybe I wanted another child!!!! Maybe there was a plan to do Hajj next year!!! Maybe a little bit of the sea was able to touch!!! maybe…… Everything in life does not happen at once... there is a time for everything. Regret cannot be kept. Before someone, after someone...But death is inevitable.... Are you ready for that?!!! - Dr. Shahadat Hossain Source: Facebook Translated by: Google https://www.instagram.com/p/ChgJRdRjh6lUwMI4b2QYLO0GMUMoHUioK1BHto0/?igshid=NGJjMDIxMWI=

[montoyagonzalez6]

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[slotfuentes7]

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[ijcmcrjournal]

Case Report of Disseminated Pseudomonas Infection with Superadded Burkholderia Infection – A Battle Lost! by Sangita K*

Abstract

Pseudomonas aeruginosa is a gram-negative pathogen, that often causes nosocomial pneumonia in hospitalized patients. Most of these patients have risk factors for pseudomonas infection. Although uncommon, there have been case reports of previously healthy individuals who developed Community-Acquired Pneumonia (CAP) caused by P. aeruginosa. Such cases have often rapidly progressive course and prove fatal. We, hereby, report a case of pseudomonas pneumonia in a 29-year-old immunocompetent patient, who developed disseminated infection and superinfection with yet another nosocomial pathogen, Burkholderiacepacia, eventually leading to septic shock and death, despite appropriate antibiotic therapy.

Keywords: Infection; Bacteremia; Pneumonia; Antibiotics; Healthy

Introduction

Community-Acquired Pneumonia (CAP) due to pseudomonas aeruginosa in a previously healthy individual is rare. Pseudomonas is a gram-negative, aerobic organism which generally infects patients with structural lung diseases like cystic fibrosis and Chronic Obstructive lung Disease (COPD) and immunocompromised host [1]. We report a rare case of P. aeruginosa CAP in a young female without risk factors that progressed to necrotizing pneumonia, with formation of cavities. Further, there was dissemination of infection to other organs resulting in metastatic abscesses in liver and spleen, superinfection with Burkholderiacepacia, eventually leading to septic shock, Multi-Organ Dysfunction Syndrome (MODS) and death, despite being treated with appropriate antibiotics.Such a case of disseminated pseudomonas infection is hitherto not described in the literature.

Case Report

A 22-year-old previously healthy lady was admitted to our hospital with history ofhigh-grade fever for 7 days accompanied by cough, productive of scanty yellowish sputum for 5 days. She had also noticed swelling of both legs, three days prior to the admission. She had undergone caesarian section 3 months prior and remained asymptomatic till 1 week prior to hospital admission. She did not have past history of any significant medical ailment and addictions. On examination, she had pallor and bilateral pitting pedal edema. There was no cyanosis, clubbing or generalized lymphadenopathy. She was febrile, pulse rate was 124/minute, regular, blood pressure was 112/70 mm Hg and respiratory rate was 22/minute with accessories working. Breath sounds were vesicular type and were diminished at both bases. SaO2 while breathing ambient air was 92%. Abdomen was fatty and there was no organomegaly. Other systems were normal.

On admission, her hemoglobin was 6.4gm/dl, mean corpuscular volume (MCV) 77.8 fl, WBC count 2,300/µL (52% neutrophils with toxic granules, 36% lymphocytes, 12% monocytes) and platelet count 51,000/cu mm. Evaluation of the cause of anemia revealed serum iron – 34.8mcg/dl, serum ferritin – 564 mcg/L, serum folic acid –5.6ng/ml, serum B12 - 442pg/ml, reticulocyte count of 0.8%, normal adult pattern hemoglobin electrophoresis and negative Direct Coomb’s Test (DCT). Renal function test was normal. Liver function test revealed serum bilirubin – 1.72 mg/dl, alanine transferase (ALT)-27.9U/L, Aspartate Transferase (AST) 40.8U/L, alkaline phosphatase (ALP)-284.4U/L, total serum protein 6.1g/dl, serum albumin- 2.07 g/dl, serum globulin – 4.03g/dl. Her coagulation tests revealed prothrombin time–13.2, control-11 secs, International Normalized Ratio (INR) 1.54 and activated partial thromboplastin time – 26.9 sec, control-24.6. C- Reactive Protein (CRP)was 29.24 mg/dl. Her viral markers (HBsag, HIV 1 and ll and HCV antibodies) were non-reactive. Her antinuclear antibodies (ANA) and antibodies to double-stranded DNA (dsDNA) were negative. Mantoux skin test was negative. Urine routine examination showed 10 to 12 pus cells/ high power field and 274.6mg/dl of protein.Her serial laboratory investigations were as tabled in the Table 1.

Chest radiograph showed left mid zone pneumonia (Figure 1) while Contrast Enhanced Computed Tomography (CECT) of thorax showed multiple small nodules and cavities in both lungs with mild left pleural effusion (Figures 2a-2d). Echocardiography was normal. Abdominal ultrasound showed hepatosplenomegaly with imaging features suggestive of multiple abscesses in liver largest measuring 6 cm x 4 cm and largest splenic abscess measuring 4 x 3.5 cm with moderate ascites while Contrast Enhanced Computed Tomography (CECT) abdomen confirmed the above findings and additionally showed few small abscesses in the right kidney (figures 3a-3d).

Her blood culture sent on the day of admission grew gram negative bacilli, pseudomonas aeruginosa (BACTEC method), which showed sensitivity to meropenem, imipenem, ciprofloxacin and piperacillin-tazobactum and resistance to amikacin, colistin, cefepime, cefaperazone-sulbactum and tigecycline. She was treated with intravenous piperacillin-tazobactum 4.5 g thrice a dayand levofloxacin 500 mg once a dayfor 10 days with other supportive measures. However, she continued to get high grade fever spikes (104 to 105F). A second blood culture sent on day 8 of admission grew Burkholderiacepacia sensitive to meropenem and ciprofloxacin. Her antiobiotic therapy was escalated to intravenous meropenem 1 g tidand oral trimethoprim/ sulfamethoxazole (80/400 mg). She, however, went into septic shock needing double vasopressor support. Shelater developed multiorgan dysfunction syndrome (MODS) and Disseminated Intravascular Coagulation (DIC) and succumbed to her illness. A final diagnosis of community acquired pseudomonas pneumonia with dissemination with metastatic abscesses with superadded Burkholderia infection leading to MODS was made.

Discussion

This patient was diagnosed to have severe Community-Acquired Pneumonia (CAP) due to P. aeruginosa, which was complicated by secondary hematogenous spread causing metastatic abscess in liver and spleen and MODS involving cardiovascular, hematologic and respiratory systems. Injury to thealveolar epithelium causes release of proinflammatory cytokines into the circulation which are ultimately responsiblefor septic shock. During treatment, she developed superadded secondary infection with Burkholderiacepacia. Pseudomonas aeruginosa is a gram-negative aerobic bacterium that causes several types of infections including wound, urinary tract, and respiratory tract infections. It is a common pathogenicbacteria in hospital acquired pneumonia, and is usually seen in patients who have structural lung disease, or are immunocompromised [1]. However, it is rarely identified as a cause of pneumonia in previously healthy individuals, accounting for 0.4–6.9% of the reported cases of CAP requiring hospitalization [2] and 1.8–8.3% CAP requiring Intensive Care Unit (ICU) admission [3]. Several studies [4,5] found that fatal P. aeruginosa pneumonia in healthy patients was associated with exposure to contaminated hot tubs. Harris et al.[6] reported a case of P. aeruginosapneumonia in a chronic asthmatic patient who was using a home humidifying device that contained water contaminated with P. aeruginosa.Other risk factors identified in various studies include bronchiectasis, cystic fibrosis, chronic heart failure, smoking, malnutrition and immunocompromised status [7]. Our patient was a home maker and there was no history of any of the above risk factors. Few studies have reported prior infection with Influenza A to be a risk factor for P. aeruginosa infection. Influenza viral infection causes respiratory epithelial cell dysfunction and apoptosis by disruption of protein synthesis and thus allowing increased bacterial adherence and invasion [1,8]. Occupational exposure in health care workers may also be a risk factor [9]. Our patient, prior to hospital admission, did not have any risk factor for pseudomonas infection. Compared to pneumonia caused by other pathogens,P. aeruginosa CAP runs a fulminant course, shows rapid dissemination and has poor prognosis[1].Semerci SYet al reported a case of hepatic and splenic abscess in a preterm infant caused by P.aeruginosa[11].Govan et al reported a case of a previously healthy 49-year-old man who died within 12 hoursofhospital admission. P. aeruginosa was subsequently isolated both from sputum and blood samples taken at the time of admission and from postmortem specimens of his lung, liver and spleen [2,12].

In a review of literature by Hatchette et al from 1966 to 2000, he reported 11 cases of P aeruoginosa[10]. Further Maharaj S et al did a review of nine cases indexed in PubMed from 2001to 2016 of which 3 were complicated by sepsis with MODS [2]. However, none of these cases were complicated by metastatic abscess formation.Predilection for the Right Upper Lobe (RUL) was seen in two-thirds of the cases of P. aeruginosaCAP described by Hatchette et al[10] and in 7 out of 9 cases by Maharaj S et al [2]. P. aeruginosais an aerobic bacterium and upper lobes provide a more favorable environment due to higher ventilation to perfusion ratios [2]. However, our patient had bilateral, multifocal involvement with cavitation in CT thorax while the chest radiograph initially showed only left mid zone involvement. As P.aeruoginosa is an invasive pathogen, and causes thrombotic endarteritis, pneumonia rapidly progresses to necrosis, with coalescing of these foci into cavities. Surprisingly the total leucocyte count was normal on admission, despite the fact that the infection was disseminated. However, there was neutrophilic leukocytosis with toxic granules seen in the neutrophils and CRP was very high suggestive of bacterial infection.Later, she went to develop neutropenic sepsis. The leucocyte count may be variable (high, normal or low) as reported by Hatchette et al [10].The current guidelines from the Infectious Diseases Societyof America(IDSA) suggest that patients with CAP who are hospitalizedin the ICU and or have risk factors like structural lung diseases, immunocompromised status, prior use of antibiotics before admission, should receive a macrolide or a fluoroquinoloneplus cefotaxime or ceftriaxone or a beta-lactam–beta-lactamase inhibitor [13].Our patient was treated as per the protocol for treatment of pseudomonas pneumonia with antipseudomonal antibiotic(piperacillin-tazobactum and clarithromycin which was escalated to meropenem, clarithromycin and co-trimoxazole), considering the possibility of emergence of resistant strains during the therapy. This was also in accordance with the antibiotic sensitivity pattern. Though earlier studies showed better prognosis in younger patients, ourpatient unfortunately did not respond to the treatment.

cepacia is a member of a group known as B. cepacia complex which includes nine differentrecognized genomovars. It is a gram-negative, glucose-non-fermenting, aerobic bacillus and causes acute systemic infection and “cepacia syndrome” which is progressive necrotizing pneumonia [14].It is associated with infections in patients with underlying lung disease, like cystic fibrosis, chronic granulomatous disease, immunocompromised individuals, hospitalized patients and drug addicts [15].Outbreaks may occur due to contaminated antiseptics, disinfectants, ventilators and other types of medical equipment [14]. Also, person-to-person spread has also been documented.In a study by Bressler et al, among ICU patients without cystic fibrosis, bacteremia due to B. cepacia was associated with renal failure requiring dialysis, recent abdominal surgery, bronchoscopies, tracheostomy, and presence of a central line [16]. In a study by Huang et al, most patients had seriouscomorbidities including diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), malignancy and congestive heart failure [15]. Our patient had central line insertion and was transferred to Intensive Care Unit (ICU). She,thus having two risk factors.The organism was sensitive to meropenem and co-trimoxazole. As she had overwhelming infection, resulting in metastatic infection in liver, splenic and renal infection, she succumbed to her illness.To our knowledge, this is the first report of pseudomonas pneumonia complicated by metastatic abscesses (liver, spleen and kidney), secondary infection with B. cepacia and MODS.

Conclusion

Pseudomonas aeruginosa, can cause CAP. The disease, although described in immunocompromised patients and with underlying risk factors, can also occur in apparently healthy individuals. The initial symptoms may not be precise enough for a specific diagnosis. Though earlier studies have shown predilection for right upper zone, pseudomonas pneumonia can be bilateral and tend to become necrotizing with cavity formation. CT thorax can demonstrate coalescing of infectiousfoci into cavities and is recommended when the initial radiograph is not contributory. The infection can disseminate to other organs as in our case and ultimately lead to septic shock despite appropriate antibiotic therapy. Superadded infection with other pathogens can also occur. Physicians must, therefore, keep this possibility in mind while diagnosing CAP, especially if there is associated septic shock and treat the patient early with anti-pseudomonal antibiotics.

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