[Septic shock after total knee arthroplasty in a patient with Waldenström macroglobulinemia]

A 58-year-old man with Waldenström macroglobulinemia (WM) was scheduled for total knee arthroplasty for left proximal-end tibial fracture. Before surgery, he took dexamethasone 2 mg orally, and his preoperative IgM level was 2,388 mg x dl(-1). The intraoperative course was favorable. Two days after surgery, he could move to a wheelchair. But, four days after surgery, he fell into septic shock with disseminated intravascular coagulation. Furthermore, cardiac arrest ocurred twice and he finally died. Autopsy revealed the large volume of turbid ascites and petechia of the digestive tract mucosa and the endocardium. However, the infection focus could be not identified. Four days after surgery, the blood culture showed extended-spectrum beta-lactamase-producing Escherichia coli. In patients with WM, abnormalities in immunoglobulins may frequently lead to infection. Decreased cellular immunity by surgical stress, may lead to severe infection. Perioperative management, such as evaluation of the indications for surgery, appropriate administration of prophylactic antibiotics, and proper selection of anesthetic must be considered.