Trouble Unannounced

An Unusual Case of Community Acquired
Pneumonia

THE CASE

A 57-year old Dutch national on a business trip to India was brought to the emergency department of Nanavati with a history of high grade fever for the past 4 days which was not subsiding with oral medications. He also had complaints of breathlessness which had started a day before the date of admission. On examination, he was found to be Tachycardiac, Tachypnoeic and was in Type 1 respiratory failure. Chest X-ray was done immediately and it showed opacities all over the left lung.

THE PROCEDURE

The patient was resuscitated using IV fl uids and started on a broad spectrum of antibiotics. HRCT of chest was done which showed lobar consolidation in the left upper lobe and patchy consolidation in bilateral lower lobes and right upper lobe with surrounding ground glass attenuation. The patient was started on non-invasive ventilation in view of worsening Tachypnoea. As the patient didn’t respond to IV fl uids he was started on vasopressor support and was intubated and ventilated in view of respiratory acidosis and worsening respiratory distress.

The patient was admitted to the ICU under Dr. Sudhir Nair − Pulmonologist. Lab results showed raised creatinine, CRP and Pro BNP levels. In view of raised creatinine and reduced urine output with mixed acidosis, the patient was started on Renal Replacement Therapy. 2D echo was normal with good LVEF of about 60%. The patient had developed severe ARDS secondary to community acquired pneumonia and was consequently started on steroids and as sepsis worsened, more antibiotics were given. He had metabolic encephalopathy, possibly due to sepsis. The patient developed critical care neuropathy and metabolic encephalopathy and would have needed prolonged ventilatory support, hence Tracheostomy was done on Day 11 of admission. He subsequently got better and vasopressors were discontinued. However, he still needed Renal Replacement Therapy. He was on weaning from ventilator trials. Subsequently the patient developed central line associated sepsis with resulting septic shock, hence antibiotics and lines were changed. He was started on CRRT in view of haemodynamic instability with need of dialysis. He started having drop in haemoglobin with occult blood in stool requiring multiple blood transfusions. An OGD Scopy was done which showed multiple esophageal ulcers. He was started on valganciclovir for the same.

THE RESULT

Gradually the patient’s condition improved, he was weaned off vasopressors and subsequently from the ventilator too. Biopsy from ulcer revealed Herpes Simplex Virus. A repeat OGD Scopy revealed complete resolution of ulcers. He was still requiring intermittent dialysis at discharge and his motor power had also improved signifi cantly. He was transferred in an air ambulance to the Netherlands where he was decannualted the very next day.

Dr. Navneet Singh

Director
Accident and Emergency
Nanavati & BLK Super
Speciality Hospital

Dr. Ravi Charan S

In charge and Coordinator
Accident and Emergency
Nanavati Super Speciality
Hospital, Mumbai