Mateja Jovanovic, Varun Jain, Sneha Galiveeti and Vimala Ramasamy
A 37 year old male with past medical history of HIV (unknown CD4+ count and viral load, on HAART with questionable compliance), IV drug abuse, presented to ER with complaints of three day cough productive of yellow/ brownish sputum, subjective fevers, chills, chest pain aggravated by coughing and deep breaths, diarrhea, vomiting. He reported being in contact with people who had flu. Vitals showed temperature of 38.3 Celsius, respirations 22/ min, heart rate of 114/min, O2 saturation of 97% which rapidly decompensated to 85% on room air. On physical exam patient was in moderate to acute distress, with rhonchi in bilateral lung fields, tachypneic, tachycardic, occasionally producing blood tinged sputum. Labs showed severe neutropenia with bands, normal hemoglobin and hematocrit, elevated lactate, and anion gap metabolic acidosis. Influenza A test was positive. Blood cultures did not show any growth, and rapid strep test was negative. Gram staining was used to identify bacterial morphology. Repeated arterial blood gas analysis showed increasing A-a gradient with progressively worsening PO2:FiO2 ratio. Chest X-ray showed infiltrates in right upper and left middle lung. He was treated for sepsis secondary to pneumonia with intravenous fluids, azithromycin and ceftriaxone (switched to vancomycin and cefepime) neupogen. Patient went into severe sepsis and septic shock, was intubated and started on vasopressors. He subsequently developed massive hemoptysis with expectoration of approximately 3 liters of blood. Patient expired after 45 minutes of resuscitation, 19 hours after admission.
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