July 2020 Critical Care Case of the Month: Not the Pearl You Were Looking For...

Yuet-Ming Chan MD¹

David C. Miller MD²

Farshad Shirazi MD³

Janet Campion MD²

¹Department of Medicine, ²Pulmonary, Allergy, Critical Care and Sleep Medicine and ³Arizona Poison and Drug Information Center

University of Arizona School of Medicine

Tucson, AZ USA

History of Present Illness

A 75-year-old man presented with unsteady gait, difficulty concentrating and abdominal pain with loose stools. One day prior to admission, he experienced waxing and waning nausea, cramping abdominal pain, one episode of emesis and loose stools. He described acute gait disorder related to difficulty with balance. Due to concern for dehydration, he drank 10-12 cans of carbonated water without further emesis. He also experienced vague and alternating sensations of feeling “hot” in half of his body and “cold” in the other half of his body. Forty-eight hours prior to presentation, he had just returned from a five-day trip to New Orleans.

PMH, SH, and FH

The patient has hypertension and hyperlipidemia that is well-controlled. Regular medicines include losartan, diltiazem, HCTZ and simvastatin. He is a professor of medicine. He had distant tobacco use with a 10 pk-yr history. He denies recreational drug use. He endorsed drinking one glass of wine per day during his recent trip. He had eaten oysters and redfin fish during his trip.

Physical Examination

• Afebrile, HR=38, RR=12, BP=134/72, O2 sat=95% on RA
• In general, patient was slightly argumentative and in obvious distress due to abdominal pain. HEENT - nonicteric, pupils reactive, moist oral mucosa
• Neck - No elevated JVP, LAD or thyromegaly
• CV - Bradycardic, regular, no murmur
• Pulmonary - Clear to auscultation all lung fields
• Abdomen - Soft with diffuse tenderness to palpation, bowel sounds present, no HSM or mass
• Lower extremities - Cool to the touch without cyanosis, intact and symmetric distal pulses
• Neuro – Cranial nerves intact, no focal motor or sensory deficits, oriented but with difficulty concentrating on thoughts, poor short-term recall, no obvious visual or auditory hallucinations.

Laboratory

Initial laboratory testing was notable for hyponatremia of 126, otherwise a metabolic panel, complete blood count, troponin, urinalysis, urine drug screen and thyroid stimulating hormone were unremarkable. EKG showed sinus bradycardia without ischemic changes. An abdominal flat plate (KUB) showed a nonspecific bowel gas pattern without evidence of obstruction. Chest x-ray was negative for acute cardiopulmonary abnormality.

He was given 1 liter of normal saline with improvement of sodium to 131, but his pulse remained low at 36. He also developed worsening nausea and mentation, was incoherent at times, and began telling staff that “I’m going to die.”

For the initial presentation of nausea, vomiting, bradycardia, hyponatremia, mental status changes, what is your leading diagnosis?

1. Acute porphyria
2. Excessive water intake
3. Neurotoxic shellfish poisoning
4. Recreational drug use
5. Small cell lung cancer

Cite as: Chan Y-M, Miller DC, Shirazi F, Campion J. July 2020 critical care case of the month: not the pearl you were looking for. Southwest J Pulm Crit Care. 2020;21(1):1-8. doi: https://doi.org/10.13175/swjpcc002-20 PDF