Case of the Month #49 Hyperinflammatory State in the Intensive Care Unit

Published 23/05/2024

What are the significant findings shown in the CXR?

  • Right lung mass - ?Infection ?Malignancy

A CT scan is arranged in ED – this is reported as being suspicious for a pulmonary abscess with some surrounding consolidation. There is also a note that the ‘not fully imaged’ liver appears enlarged. A respiratory opinion suggests that antimicrobial treatment is the first line in this case.

The bloods taken in ED show the following;

 

Value

Normal range

WBC (x 109/L)

16.9

4-11

Hb (g/L)

75

115-160

MCV (fl)

89.7

77-98

PLT (x 109/L)

380

150-400

Neutrophil (x 109/L)

15.4

2-7.5

Lymphocyte (x 109/L)

0.5

1.5-4

CRP

180

<5

 

The remaining bloods were normal at this point

The patient was admitted to the infectious diseases ward and treated for pneumonia with broad spectrum antibiotics, HAART was also started. A CD4 count is measured and returns at 25 cells/mm3.

Despite treatment on the ward the patient becomes more hypoxic and is admitted to critical care for intubation and ventilation. Over the next 72 hours she becomes oliguric and her blood picture deteriorates – she is commenced on CVVH for her renal function. Despite antimicrobials, she remains pyrexial at 39.1, but her procalcitonin remains low (0.3).

Bloods Pre CVVH

 

Value

Normal range

WBC (x 109/L)

10.4

4-11

Hb (g/L)

64

115-160

MCV (fl)

81.0

77-98

PLT (x 109/L)

29

150-400

Neutrophil (x 109/L)

1.3

2-7.5

Lymphocyte (x 109/L)

1.1

1.5-4

CRP

270

<5

Sodium (mmol/L)

136

133-146

Potassium (mmol/L)

4.5

3.5-5.3

Bicarbonate (mmol/L)

22-29

22-29

Chloride (mmol/L)

102

95-108

Urea (mmol/L)

18.3

2.5-7.8

Creatinine (umol/L)

259

50-120

Total bilirubin (umol/L)

29

<21

ALT (u/L)

42

1-40

ALP (u/L)

136

30-130

GGT (u/L)

45

<45