Correct!
5. All of the above
Each of these is a diagnostic consideration. Sepsis syndrome secondary to Staphylococcus aureus related to his skin lesions, foreign body (subcutaneous pump) or from pneumonia id possible. Pneumonia secondary to aspiration which occurred while he was unconscious or during intubation is possible. Neuroleptic malignant syndrome or serotonin syndrome can present with high fever, increased muscle tone, delirium, respiratory failure and multisystem organ failure mimicking septic shock. Although we weren’t given a history of the use of neuroleptic medications or serotonin reuptake inhibiters, this history should be specifically investigated. Benzodiazepam withdrawal can present with a similar clinical picture when severe – such patients may also suffer agitated delirium and seizures, but usually don’t have high fevers or increased muscle tone.
The patient underwent bronchoscopy with bronchoalveolar lavage. Polymorphonuclear leukocytes were elevated at 56% in the bronchoalveolar lavage fluid but smears for organisms were negative. He was treated with piperacillin/tazobactam, gatifloxacin, baclofen 25 mg enterally every 6 hours, dantrolene 50 mg every 6 hours and repeated midazolam boluses.
The following morning he was alert and extubated. However, He rapidly subsequently deteriorated. Within the hour he required reintubation, developed a fever to 105.5 degrees F with a heart rate of 150 beats/min. Board-like muscle rigidity was noted.
An electrocardiogram revealed anterolateral ST elevations and cardiac enzymes were elevated with a troponin of 21 μg/ml and a creatinine phosphokinase (CPK) of 2120 IU/L with an MB fraction of 7.6%.
He remained hypotensive and cardiology consultation was obtained. Cardiac catherization revealed an ejection fraction of 10% and a pulmonary artery wedge pressure of 44 cm H20. His coronary arteries were normal. Levophed, dobutamine, and nesiritide were administered and an intra-aortic balloon pump was used for his refractory hypotension.
Which of the following could explain his reduced ejection fraction and hypotension?