Contributed by Timothy Gorrill, MD, PhD and Larry Nichols, MD
A 25-year-old white male with a history of schizoaffective disorder was brought to the emergency room in February with a 24-hour history of difficulty breathing and not acting normally.
On admission his temperature was 36.8 degrees, pulse 140/minute, blood pressure 122/58 mm Hg, respirations 18/minute, oxygen saturation 89% on room air, and 94% on supplemental oxygen at 4 liters/minute via nasal cannula. The patient was awake and shook his head yes and no to answer questions. He was in mild respiratory distress. He had scattered rhonchi bilaterally. His abdomen was soft, with bowel sounds present. His skin was warm and dry. Chest x-ray showed large areas of consolidation in the right midzone and right base and in the left midzone compatible with bilateral pneumonia. Electrocardiogram showed sinus tachycardia. His white blood cell count was 1,700/cu mm (28% neutrophils, 9% bands, 48% lymphocytes, 13% monocytes, 2% atypical lymphocytes), hemoglobin 15.3 g/dL, platelet count 129,000/cu mm, bilirubin 1.1 mg/dL, alkaline phosphatase 36 IU/L, alanine aminotransferase 29 IU/L, aspartate aminotransferase 47 IU/L, albumin 3.1 g/dL and creatinine 2.1 mg/dL. Sputum Gram stain showed heavy epithelial cells, heavy Gram-positive cocci in pairs, heavy Gram-negative rods and no polymorphonuclear cells. The patient was started on vancomycin, cefepime and ciprofloxacin empirically. His temperature rose to 41 degrees and respiratory rate to 40/minute. Arterial blood showed pH 7.309, pCO2 31.3 mm Hg, pO2 53.1 mm Hg, bicarbonate 15.3 mmol/L and saturation 84.1%. The patient was intubated. He became hypotensive with systolic blood pressure as low as 79/41 mm Hg, and he was started on a norepinephrine drip. His creatine phosphokinase was 915 IU/L and lactate 5.8 mmol/L. His white blood cell count fell to 1,100/cu mm, hemoglobin to 11.1 g/dL, platelets to 84,000/cu mm and albumin to 1.7 g/dL.
On hospital day 2, the patient was afebrile on acetaminophen and a cooling blanket. His blood pressure was 82/35 mm Hg (on norepinephrine) and respiratory rate 20-30/minute. Arterial blood showed pH 7.173, pCO2 41.7 mm Hg and pO2 71.7 mm Hg on mechanical ventilation with 100% oxygen. His white blood cell count was 600/cu mm (20% neutrophils, 76% lymphocytes, 4% monocytes), hemoglobin 12.1 g/dL, platelets 68/cu mm and creatinine 1.6 mg/dL. Phenylephrine and continuous renal replacement therapy were started. Oseltamivir and amantadine were added empirically. On day 3, the patient's condition deteriorated; filgrastim and vasopressin were added. On day 4, the patient's condition continued deteriorating and on day 5, at 2:50 AM, the patient suffered a cardiac arrest and could not be resuscitated.
An autopsy was performed. Figure 1 shows the appearance of the trachea and mainstem bronchi. Figure 2 is a low-power photomicrograph of lung with the arrow pointing to a feature seen to better advantage in Figure 3. Figure 4 is a high power photomicrograph of the agent of death.