OK guys time for the update:
So Rolando was hypotensive after intubation. You guys are right that the Propofol contributed to the drop in his blood pressure. However, many times patients who are in respiratory distress have a surge of catecholamines which artificially increases their blood pressure and once you knock off the offending stimuli (respiratory distress), the blood pressure tanks. Rolando was actually started on pressors.
The ED continued to struggle with profound hypoxemia and transferred him to the ICU at the community hospital where his subsequent CXR showed worsening bilateral fluffy infiltrates. His pO2 remained low and he started having hypercarbia as well. He quickly presented with a septic picture and was on high doses of Norepinephrine. The community hospital decided that Rolando was too sick to be cared for in that setting and called the nearest tertiary facility for higher level of care.
That's when we started taking care of him. Our facility has an ECMO program. Rolando was cannulated for Veno-Arterial Extracorporeal Circulatory Life Support. He was in multi-organ failure involving his circulatory system (distributive shock), respiratory system (hypoxemic and hypercarbic respiratory failure due to acute lung injury from infection requiring ECLS), and renal (acute kidney injury from acute tubular necrosis requiring continuous renal replacement therapy with CVVHD).
The community hospital updated us of his culture results: as many of you suspected, his respiratory secretions grew Coccidiodes spp
. He had Valley Fever
which has progressed to Disseminated Coccidiomycosis
. Valley Fever is caused by a fungus of the Coccidiodes genus.
A note about Coccidial Infection:
- the organism that causes this disease is endemic to Southern Arizona, Southern and Central Valleys of California, Southwestern New Mexico, and Western Texas.
- infectious manifestations vary from very mild to severe disseminated pulmonary and extrapulmonary disease. Immunocompromised hosts are at high risk for severe infections (those with HIV, transplant recipients on immunosuppressive therapy, patient on chemotherapy, etc).
- there are reports that people of Native American, African, and Philippine descent tend to present with severe cases. A study in California, however, did not support the evidence that people of Asian (Philippine) and Hispanic racial or ethnic background are at risk for severe cases (see link
- treatment with antifungals such as Fluconazole and Itraconazole are recommended. Amphothericin B may be considered in severe cases with the caveat that toxicity can be problematic. Newer antifungals such as Voriconazole or Posaconazole have not been well studied on its effectiveness in Coccidiomycosis.
Rolando's Hospital Course:
Perhaps owing to his healthy state prior to his infection and his age, Rolando improved clinically on ECLS and was eventually decannulated from the bulky device. He was eventually taken off pressors as well. He remained on intermittent dialysis for a period of time but subsequently had return of his kidney function. He luckily did not require a tracheotomy as his neurologic status was unaffected (his CSF was negative for cocci) and was extubated as soon as his ventilatory settings were down to minimum support.
He was transferred to a regular hospital floor after about a couple weeks in the ICU. He went home with his mother after his hospital stay.