PMC:7253233 / 4888-8341 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/7253233","sourcedb":"PMC","sourceid":"7253233","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7253233","text":"Case #1\nA 76-year-old male with history of chronic asthma on benralizumab, hypertension, chronic kidney disease, hyperlipidemia, left bundle branch block, diastolic dysfunction, and cervical fusion presented to the emergency department with the chief complaint of severe right lower extremity pain, fever (102.5 °F on presentation), and encephalopathy. He was status post recent L3-S1 laminectomy for acute lumbosacral radiculopathy 5 days prior to presentation. Laboratory workup showed neutrophilic leukocytosis (17,200 cells/mm3). He had a Glasgow coma scale of 14, was oriented to name only, and exhibited exaggerated deep tendon reflexes but had no other focal neurological deficits. A computerized tomography (CT) scan of the brain was unremarkable. Magnetic resonance imaging (MRI) of the spine revealed an epidural abscess between L4-S1. Surgical drainage was performed, and the patient was started empirically on vancomycin and piperacillin–tazobactam. Wound cultures grew Pseudomonas aeruginosa. Despite antibiotic therapy, and improved leukocytosis, he continued to have high-grade fevers and acute hypoxemic respiratory failure requiring intensive care unit transfer on postoperative day 1. He was initially managed conservatively with diuresis, preload, and afterload optimization; however, his chest X-ray rapidly progressed to bilateral interstitial and airspace opacification (Fig. 1).\nFig. 1 Chest X-ray showing bilateral lung infiltrates (a) compared to his baseline (b)\nOn postoperative day two, the patient suffered several episodes of left upper extremity clonic activity and worsening encephalopathy with decline in level of consciousness as evidenced by increased drowsiness and inability to follow commands. Continuous electroencephalography (EEG) confirmed three focal seizures lasting approximately 30 s each arising from the right centroparietal region (Fig. 2). Levetiracetam was initiated and both clinical and electrographic seizure activity subsided. Antibiotic regimen was broadened to Vancomycin, Meropenem, and Acyclovir for CSF coverage. MRI of the brain and cervical spine with and without contrast was remarkable only for chronic white matter hyperintensities, without acute intracranial lesions, meningeal enhancement or venous sinus thrombosis, and C5–C6 myelomalacia, respectively. Lumbar puncture was not performed due to the risk of seeding infection into neuroaxis. Given persistent high-grade fevers, worsening respiratory status requiring intubation, and recent possible exposures, a respiratory viral panel was sent in addition to separate rapid testing for COVID-19 polymerase chain reaction on postoperative day 4 and COVID-19 testing was confirmed as positive twenty-four hours later. His fibrinogen level was elevated at 631 mg/dL (normal range 200–400 mg/dL) and continued to increase to over 860 mg/dL over the following days. C-reactive protein increased from 1.7 mg/dL on prior admission to 27.3 mg/dL and remained elevated despite antimicrobial therapy. White blood cell count steadily improved over his hospitalization, and platelet count remained stable. Our patient ultimately received a tracheostomy and after 30 days of ICU stay was discharged to a long-term acute care hospital for further ventilator management.\nFig. 2 Electroencephalography. Rhythmic discharges noted in the right frontocentral/vertex region (red box) corresponding to clonic movements of the left arm (Color figure 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