Grand Rounds—City Hospital, Nottingham: A complicated case of community acquired pneumonia

Beware of drug induced side effects in critically ill people

Community acquired pneumonia is an important cause of morbidity and mortality in young people. Patients needing intensive care often have multiple organ failure and need large doses of different drugs; they are therefore at high risk of side effects of drugs, although these side effects may be difficult to detect.

Case history

A 32 year old, non-smoking, white woman was admitted to this hospital as an emergency with cough and breathlessness in late December 1993. She had been well until two weeks previously, when she developed headache and nausea followed by a cough with scanty sputum and progressive dyspnoea with orthopnoea. Her general practitioner prescribed amoxycillin with clavulanic acid on the day of admission. She was a part time cleaner; drank no alcohol; had no history of foreign travel, intravenous drug use, or blood transfusion; and kept no pets.

On admission she was unwell, cyanosed, and breathless at rest but alert, oriented, and without fever. The main abnormal signs were a raised heart rate (140 beats/min), jugular venous pressure (5 cm), and respiratory rate (32 breaths/min); a low systolic blood pressure (70 mm Hg); left basal crackles; and a third heart sound. A chest radiograph showed extensive consolidation of the mid-zones and lower zones in both lungs (fig 1). The electrocardiogram showed sinus tachycardia and inferior T wave inversion. Arterial blood gas tensions taken with the patient breathing room air showed a pH of 7.51 and oxygen and carbon dioxide tensions of 4.9 and 3.3 kPa respectively (oxygen saturation 78%). The following routine blood tests yielded abnormal results: total white cell count (17 x 10⁹ (82% neutrophils)) and serum concentrations of sodium (129 mmol/l), urea (18.8 mmol/l), creatinine (122 µmol/l), and albumin (29 g/l).

Severe community acquired pneumonia with myocardial dysfunction was diagnosed, …