October 2019 Critical Care Case of the Month: Running Naked in the Park

Spencer Jasper MD

Matthew Adams DO

Jonathan Boyd MD

Jeremiah Garrison MD

Janet Campion MD

The University of Arizona College of Medicine

Tucson, AZ USA

History of Present Illness

A 34-year-old man with a history of IV drug abuse was brought into emergency department by EMS and Tucson Police Department after complaints of naked man running and behaving erratically in a park. On arrival to emergency department patient was acting aggressively towards staff, spitting and attempting to bite. The ER staff attempted multiple times to sedate the patient with benzodiazepines, however, due to continued aggressive behavior, ongoing encephalopathy and the need for increased sedation, the patient was intubated for airway protection.

The patient was febrile (40.6° C), tachycardic (122) and hypertensive (143/86). On physical exam patient was not cooperative, was diaphoretic, cachectic, with reactive constrictive pupils, track marks in antecubital fossa bilaterally. No clonus or hypertonicity. During intubation, there was noted to be nuchal rigidity.

He was then admitted to the medical ICU. Drug intoxication from possible methamphetamines was the presumptive diagnosis of encephalopathy but given nuchal rigidity and fevers there was concern for other etiologies.

Physical Exam

• Vitals: T 40.6 °C, HR: 122, RR: 22, BP: 143/86, SpO2: 97% WT: 55 kg
• General: Intubated and sedated, cachectic
• Eye: Pupils constricted but reactive to light
• HEENT: Normocephalic, atraumatic
• Neck: Stiff, non-tender, no carotid bruits, no JVD, no lymphadenopathy
• Lungs: Clear to auscultation, non-labored respiration
• Heart: Normal rate, regular rhythm, no murmur, gallop or peripheral edema
• Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses
• Skin: Skin is warm, dry and pink, multiple abrasions on the lower extremities bilaterally, track marks noted in the antecubital fossa bilaterally. Large abrasion with bruising around the right knee and erythema and welts on the right shin. Erythematous area on the dorsal surface of the right hand
• Neurologic: Nonfocal prior to intubation, no clonus or hypertonicity noted

Drug overdose/intoxication was presumptive diagnosis for his acute encephalopathy. Based on physical exam and vitals, what other etiologies should be considered? (click on the correct answer to be directed to the second of seven pages)

1. Embolic stroke
2. Heat stroke
3. Hyperthyroidism
4. Meningitis
5. All of the above

Cite as: Jasper S, Adams M, Boyd J, Garrison J, Campion J. October 2019 critical care case of the month: running naked in the park. Southwest J Pulm Crit Care. 2019;19(4):110-8. doi: https://doi.org/10.13175/swjpcc054-19 PDF

August 2017 Critical Care Case of the Month

Kolene E. Bailey, MD¹

Carolyn Welsh, MD^1,2

Pulmonary Sciences and Critical Care Medicine

¹University of Colorado Anschutz Medical Campus and ²VA Eastern Colorado Health Care System

Denver, CO USA

History of Present Illness

The patient is a 26-year-old woman with who was admitted to the hospital for second cycle of chemotherapy for a large mediastinal synovial sarcoma diagnosed 2 months prior to admission. Symptoms started 6 months prior to presentation with cough. She related the cough to her cigarette smoking and quit. Upon persistence of symptoms, she was evaluated by her physician who ordered imaging. Work-up revealed a large 12 x 14cm synovial sarcoma with internal necrosis that encased the subclavian artery, and descending thoracic aorta, inseparable from pericardium and left atrium. It also encased the pulmonary veins, pulmonary arteries, and airways. Malignancy was complicated by extensive left upper extremity DVT for which she has been on anticoagulation since her last admission, SVC syndrome, and severe mucositis.

Past Medical History, Family History, and Social History
She has a past medical history significant for malignant melanoma surgically resected 7 years previously, as well as generalized an anxiety disorder.

Her family history includes a maternal grandfather with esophageal cancer and maternal great-grandmother with pancreatic cancer. She is single and lives with her parents. She is a former 8 pack year smoker, and daily edible marijuana user. She worked as a hairdresser, but is now unable to work.

Current Medications:

• Escitalopram (Lexapro) 10mg PO daily
• Dalteparin
• Oxycontin 10mg PO BID + Oxycodone 5-10mg PO Q4H PRN pain
• Antiemetics: Compazine PRN, Ondansetron PRN, dexamethasone 4mg BID for 3 days following chemotherapy
• Lorazepam 1mg PO Q4H PRN anxiety
• Pegfilgastrim after chemotherapy
• Senna 3 tabs in AM, 2 tabs in PM

Hospital Course

After starting cycle #2 of chemotherapy (doxorubicin, ifosfamide, and mesna), she experienced significant nausea and anxiety and was prescribed scheduled ondansetron/dexamethasone, prochlorperazine, promethazine and lorazepam. The night of hospital day #2, her providers noticed altered mental status and unusual behavior. They asked her draw a clock which is shown (Figure 1).

Figure 1. Clock drawn by patient.

What is on your differential diagnosis for this patient’s altered mental status? (Click on the correct answer to proceed to the second of five pages)

1. Delirium
2. Ifosfamide-induced encephalopathy
3. Toxic-metabolic encephalopathy secondary to the medications received
4. 1 and 3
5. All of the above

Cite as: Bailey KE, Welsh C. August 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;15(2):61-6. doi: https://doi.org/10.13175/swjpcc094-17 PDF