A 48-year-old Arab lady who is on injection Humira for Rheumatoid arthritis was wheeled to the ED with shortness of breath after being to multiple hospitals. She had travelled prior to Turkey and UAE.

Her CT had features suggestive of Atypical Pneumonia with elevated CRP and white blood cell counts. The work up for Viral pneumonia came negative. She was admitted and managed conservatively with broad spectrum antibiotics and supportive care. She continued to worsen with acute respiratory failure and the ICU team had to take control of the patient.

She was under the care of a multidisciplinary team of specialists and consultants- the best in their respective fields. Her respiratory secretions were sent for bio fire analysis. Her oxygen levels were critically low and subsequently she had to be ventilated prone to sustain. She was managed with antibiotics Inj. Carbapenem and Quinolone. She was managed with a larger venous access and was on invasive hemodynamic monitoring. All labs including cultures and other investigations in accordance with Sepsis protocol were sent.

However, her renal and liver parameters started deteriorating. Vasculitis was suspected however further work up done, found her to be positive for SLE- an overlap with Rheumatoid arthritis.

She was managed as Severe Respiratory Sepsis in failure with multi organ dysfunction including Acute kidney injury and overlap syndrome.

Her Bio fire reports came positive for Legionella pneumonia. She was prone ventilated for 5 days and was off ventilator by day 10. She continued to have high grade fever and elevated white blood counts despite being on broad spectrum medications. Her blood and urine cultures were negative. 

Her antibiotics were modified to Meropenem and Clarithromycin and in 48 hours she turned afebrile and the white blood cells normalized, possibly a partially treated condition with the other two antibiotics given earlier. She was shifted out of the ICU on Day 12. She was continued on IV Clarithromycin for 5 days and orally subsequently and later discharged. She had critical illness polyneuropathy which gradually improved in the next 4-6 weeks and now she can walk normally.

The family and patient were very grateful, and they gave heartfelt feedback subsequently when they came for review on the care offered by the team, ICU nurses and our skilled physiotherapists.

A skilled team working together catered to her care inclusive of Dr. Surendar Singh (Specialist physician), Dr.Dilip Abdul Khadar (Specialist Physician- Intensivist), Dr. Muthu Manikandan (Specialist Anesthesiologist), Dr. Farooq (Nephrologist), Dr. Ashik Sainu (Consultant gastroenterologist), Dr. Lekha (Specialist Anesthesiologist), Dr. Narendra  (Specialist Anesthesiologist), Dr. Binoy (Specialist Anesthesiologist), Dr. Meher Ali (Consultant & Interventional cardiologist), Dr. Sukhbir (Consultant Rheumatologist), Dr. Achint (Specialist Neurologist) and Dr. Pranjal ( Pathologist).

Writer Bio

Dr. Dilip Abdul Khadar is an esteemed expert in internal medicine and critical care located in Muscat. His primary areas of expertise include critical care, acute medicine, management of medical and cardiac emergencies, patient care and safety after surgery, trauma care, and procedures such as the insertion of central venous catheters, chest tube drains, invasive hemodynamic monitoring, mechanical ventilation for hemodynamically unstable cases, and ongoing care for critically ill patients.

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