Veronica Arteaga

A 48-Year-Old Woman With Headache and Respiratory Failure

A 48-year-old woman presented to the ED with headache, nausea, and fever of 2-day duration. She denied any other symptoms, except for some vague malaise and fatigue for several weeks prior to presentation. She denied dyspnea, cough, chest pain, rash, joint swelling, and bruising. Her past medical history was signifi cant for migraine headaches, gastroesophageal refl ux disease, and three uneventful pregnancies. Her family history was unremarkable; she did not smoke cigarettes or use illicit drugs, and she drank alcohol occasionally. She was visiting Arizona from a mid-south state. Physical examination revealed a woman in mild distress due to headache but with normal respiratory effort. Her vital signs were as follows: temperature, 38.9°C; BP, 103/63 mm Hg; respiratory rate, 18 breaths/min; pulse rate, 113 beats/min; and arterial oxygen saturation, 92% on room air. She had no neck stiffness. Her mental status was normal, and the neurologic examination fi ndings were unremarkable. There were no skin rashes. She was warm and well perfused, and her breath sounds were clear and symmetric. In the ED, a lumbar puncture was performed but fi ndings were unremarkable. The initial chest radiograph showed mild, nonspecifi c, bibasilar opacities and the presence of a hiatal hernia ( Fig 1A ). Her blood chemistry results at admission revealed mild hypokalemia (3.3 mM/L) and hyponatremia (131 mM/L). A CBC count showed mild leukocytosis (16.5 3 10 3 / m L ) of neutrophilic predominance (87%) and eosinophilia (3%; absolute eosinophil count, 0.43 3 10 3 / m L). Results of cerebrospinal fl uid analysis were within normal limits. The patient was admitted to the medicine service for pain control and further evaluation of possible early sepsis. During the fi rst hospital day, she developed dyspnea and hypoxemia. The treating physicians suspected community-acquired pneumonia and started treatment with ceftriaxone and azithromycin. The patient’s level of consciousness remained intact during this time, and there were no witnessed episodes of aspiration. Her chest examination revealed bilaterally decreased breath sounds at the bases with scattered coarse breath sounds. The rest of her examination was unremarkable. On the second hospital day, she developed hypoxic respiratory failure. Endotracheal intubation was A 48-Year-Old Woman With Headache and Respiratory Failure

Medical image of the week: pulmonary infarction- the “reverse halo sign”

Figure 1. CT Chest with contrast. Two different levels in the same patient displayed on mediastinal windows. Several triangular shaped subpleural lesions with annular peripheral solid appearance are depicted, better characterized in the lung windows below (yellow arrows). Note the partial filling defect (red arrow on B), indicating a non-occlusive thrombus(arrow). Bilateral pleural effusions are also identified.

Medical image of the week: PE with infarct and pulmonary cavitation

Figure 1. Panels A & B: thoracic CT scan showing multiple pulmonary emboli (arrows). Panel C: frontal chest radiograph showed extensive left lung opacification most dense in the left upper lobe. Panel D: frontal chest radiograph taken 3 weeks later showing mild volume loss of the left upper lobe with a large lucency suggestive of cavitation (arrow). Panel E: thoracic CT scan confirming the cavitation.