What are the salient features of the case? A 52-year-old female presented to the emergency department (ED) resuscitation unit with a 5-day history of progressive shortness of breath and productive cough of green sputum. She described some brief episodes of hot and cold spells but had no documented fever or rigors. She was too tachypnoeic to further offer any history. Vitals on presentation were as follows: pulse oximeter reading of 78% on room air, heart rate (HR) of 110 bpm, blood pressure of 85/60 mmHg, respiratory rate of 37 breaths per minute, and temperature of 35.4°C. Initial management was commenced by the ED physicians. A brief collateral history was obtained from her daughter. The patient was visiting Ireland on holiday and had arrived 6 days ago from Minnesota, USA. Her past medical history included chronic migraine, genital herpes, and zika virus infection, which was acquired 2 months ago during a visit to Mexico and was treated supportively. She was an ex-smoker with 10-year pack history, and her alcohol intake was described as moderate by her daughter. Her medications included hydrocodone, topiramate, and gabapentin all of which she had been on for more than 2 years. She had no history of staying in motels, cruise ships, exposure to birds, purchase of new pets, sick contact, intravenous drug usage, or tick bites. Her chest radiograph showed multiple foci of consolidation representing multifocal pneumonia or possible pulmonary infarcts secondary to multiple pulmonary emboli. Blood results (Table 1) showed a CRP of 516 mg/L, urea of 28 mmol/L, creatinine of 163 μmol/L, and D-dimer of 1400 ng/ml and a mixed respiratory metabolic acidosis with type 2 respiratory failure on arterial blood gas. Microbiology on call was contacted, and she was commenced on broad spectrum coverage with piperacillin-tazobactam, clarithromycin, vancomycin, and oseltamivir. Bilevel positive airway pressure (BIPAP) as a form of noninvasive ventilation was commenced, with ICU involvement. An urgent CT-pulmonary angiogram was arranged (Figure 2) and showed no acute pulmonary emboli, extensive multifocal consolidations, and most likely reactive mediastinal lymphadenopathy.
What are the salient features of the case?
A 52-year-old female presented to the emergency department (ED) resuscitation unit with a 5-day history of progressive shortness of breath and productive cough of green sputum. She described some brief episodes of hot and cold spells but had no documented fever or rigors. She was too tachypnoeic to further offer any history. Vitals on presentation were as follows: pulse oximeter reading of 78% on room air, heart rate (HR) of 110 bpm, blood pressure of 85/60 mmHg, respiratory rate of 37 breaths per minute, and temperature of 35.4°C. Initial management was commenced by the ED physicians.
A brief collateral history was obtained from her daughter. The patient was visiting Ireland on holiday and had arrived 6 days ago from Minnesota, USA. Her past medical history included chronic migraine, genital herpes, and zika virus infection, which was acquired 2 months ago during a visit to Mexico and was treated supportively. She was an ex-smoker with 10-year pack history, and her alcohol intake was described as moderate by her daughter. Her medications included hydrocodone, topiramate, and gabapentin all of which she had been on for more than 2 years. She had no history of staying in motels, cruise ships, exposure to birds, purchase of new pets, sick contact, intravenous drug usage, or tick bites.
Her chest radiograph showed multiple foci of consolidation representing multifocal pneumonia or possible pulmonary infarcts secondary to multiple pulmonary emboli.
Blood results (Table 1) showed a CRP of 516 mg/L, urea of 28 mmol/L, creatinine of 163 μmol/L, and D-dimer of 1400 ng/ml and a mixed respiratory
An urgent CT-pulmonary angiogram was arranged (Figure 2) and showed no acute pulmonary emboli, extensive multifocal consolidations, and most likely reactive mediastinal lymphadenopathy.
Step by step
Solved in 2 steps
