12 years of recurrent distributive shock episodes – Where to look when a search for common causes comes up short?

Shock is a state of circulatory failure with common etiologies to include sepsis, cardiac dysfunction, hemorrhage, and vascular flow obstruction. Accurate and timely identification of the etiology of shock is essential to prevent multi-organ dysfunction and death. This is a case of a 69-year-old female who presented with 12 years of recurrent shock episodes thought to be due to recurrent sepsis of unknown source. Despite an exhaustive review of infectious sources and other common shock etiologies, a durable explanation for shock was not found. A review of chronic medications demonstrated concurrent chronic use of lisinopril and verapamil; with discontinuation of lisinopril her episodes of recurrent shock ceased. Concurrent use of ACE-I and CCB can suppress native sympathetic cardiovascular responses to insignificant hemodynamic insults. Therefore, going back to the basics with a review of exogenous variables (i.e. medications) is an essential first step in identifying the cause of recurrent episodes of shock when no other common unifying etiology can be identified.