September 2012 Critical Care Case of the Month

Robert A. Raschke, MD

Banner Good Samaritan Regional Medical Center

Phoenix, AZ

History of Present Illness

A 45 year old man was transferred from another medical center. He was found unresponsive, with muscle spasticity. After arrival at the outside medical center his vital signs were temperature 106.4 degrees F, heart rate 160 beats/min, respiratory rate 44 breaths per minute, and BP of 70/45 mm Hg. He was orally intubated for respiratory distress with induced by vecuronium.  His white blood cell count was 21,000 cells/μL. Chest x-ray showed bilateral consolidations and he was given fluids and gatifloxacin. His blood pressure improved to 130/94 and he was transferred.

PMH, SH, FH

He has a past medical history of quadriplegia at the C6 level with a history of severe back pain because syringomyelia.  He has a history of autonomic dysreflexia. Despite his disability he is quite functional working as a personal injury lawyer. He had been managed with a variety of medications including benzodiazepams, narcotics and baclofen. The later two were administered via an intrathecal pump which had been weaned over several weeks, and totally discontinued the day prior to admission. There is no history of smoking or alcohol abuse.

Physical Examination

His vital signs were temperature of 102.6 degrees F, heart rate 160 beats/min,  respiratory rate 14 breaths per minute, and BP of 130/50 mmHg.

He was paralyzed and mechanically ventilated. There was tenting of the skin and mottling of neck and knees. He had calloused hands and excoriated forearms. Lungs had diffuse rales and the heart rate was regular but rapid. A subcutaneous pump device was palpable in the left lower abdominal quadrant. There was a pressure sore on the coccyx.

Admission Laboratory and X-ray

His admission chest x-ray showed a diffuse 5-lobe consolidation. White blood cell count was elevated at 21,000 cells/μL.

At this time which of the following are diagnostic possibilities?

1. Sepsis secondary to Staphylococcus aureus
2. Pneumonia secondary to aspiration
3. Neuroleptic malignant syndrome
4. Benzodiazepam withdrawal
5. All of the above

Reference as: Raschke RA. September 2012 critical care case of the month. Southwest J Pulm Crit Care 2012;5:121-5. (Click here for a PDF version)