B is the correct answer. Why?

Explanation

This patient is presenting with hypotension likely caused by infection given his multiple skin abscesses and areas of cellulitis. He does not respond to appropriate fluid resuscitation, suggesting he is in septic shock. Sepsis is end-organ dysfunction that occurs as an inflammatory response to an infection resulting in impaired perfusion and endothelial dysfunction. Septic shock is when a patient’s blood pressure fails to correct despite adequate fluid resuscitation (typically defined as 30 mL/kg of fluid) and vasopressors are needed to maintain blood pressure(with a mean arterial pressure of 65 mm Hg being a common goal). In addition to fluids and vasopressors, early administration of broad-spectrum antibiotics improves outcomes and is critical in management. The initial workup of sepsis and septic shock should always include basic laboratory studies such as a complete blood count and a complete metabolic panel. At least two blood cultures should be drawn from two different locations. Further workup should search for the etiology of infection and must include a thorough dermatologic exam, a urinalysis and urine culture, and a chest radiograph. Central nervous system imaging may be indicated if an intracranial infection, such as abscess, is suspected. A lumbar puncture for cerebrospinal fluid analysis and culture should be considered if there is not a clear alternative etiology for infection or if there are clear signs of meningitis or encephalitis. Further diagnostic and imaging tests should be titrated to the suspected diagnosis. A prognostic indicator in septic shock and a marker of success in resuscitation is the serum lactate. Lactate is produced when an end organ is not perfused and has to rely on anaerobic (rather than aerobic) metabolism. Anaerobic metabolism produces lactate. As a patient is resuscitated, end organs should switch from anaerobic back to aerobic metabolism while the lactate is cleared from circulation (typically by the liver). Thus, the lactate can be trended in septic shock and a declining lactate level could suggest an improvement in the shock state.

C-reactive protein (A) is an inflammatory marker that is nonspecific. While it would be elevated in most cases of septic shock, the extent of elevation is not particularly prognostic. Moreover, serial C-reactive protein levels are not particularly useful in guiding resuscitation. The procalcitonin (C) level is often used to suggest if an infection is viral or bacterial. The classic teaching is that an elevated procalcitonin level suggests a bacterial infection. While this marker may be useful to guide thinking, if a bacterial source of infection is suspected, then antibiotics should be started regardless of the procalcitonin level. Moreover, a low procalcitonin level does not eliminate the need for antibiotics. Trending the procalcitonin may allow for patients to be titrated off of antibiotics sooner, resulting in improved antibiotic stewardship. The white blood cell count (D) is often elevated in infection. However, the presence or absence of an elevated white blood cell count does not definitively rule in or out an infectious cause of a patient’s hypotension.