Fig. 1
Chest X-Ray (Single View) on Day 3 of Hospitalization
Fig. 2
Chest CT Angiography on Day 2 Of Hospitalization
Table 1
Example of Inflammatory Markers Trended Early in Patient’s Hospital Course
| Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Day 6 | |
|---|---|---|---|---|---|---|
| PT | 12.8 | N/A | 15.3 | N/A | 15.0 | N/A |
| D-dimer | 1.6 | 1.3 | 1.6 | 1.3 | 4.4 | > 21 |
| LD | 202 | 202 | 392 | 500 | 691 | 1,175 |
| Fibrinogen | 492 | 555 | 891 | 827 | N/A | 570 |
Table 2
Ventilation Settings and Corresponding Arterial Blood Gas (ABG) Values
| Hospital Day # | Ventilation Mode | PEEP (cm H2O) | Respiratory Rate (bpm) | FiO2 (%) | Tidal Volume (Vt; mL) | Arterial Blood Gas Values (pH/ paCO2/paO2/HCO3) | Ventilator Changes2 |
|---|---|---|---|---|---|---|---|
| 31 | AC/VC | 12 | 16 | 100 | 400 | 7.33/39/184/19.7 | ↓ FiO2 to 50% |
| 4 | AC/VC | 12 | 20 | 60 | 400 | 7.28/46/86/21.5 | ↓ FiO2 to 50%; ↑ RR to 26 bpm |
| 5 | AC/VC | 16 | 26 | 100 | 390 | 7.32/43/133/21.7 | ↓ FiO2 to 90%; ↑ Vt to 400 mL |
| 6 | AC/VC | 18 | 23 | 90 | 400 | 7.37/41/118/23.2 | ↓ FiO2 to 80%; ↑ Vt to 300 mL |
| 73 | AC/VC | 16 | 28 | 65 | 300 | 7.07/99/162/27.6 | ↓ FiO2 to 60%; ↑ RR to 32 bpm; ↑ Vt to 320 mL |
| 8 | AC/VC | 10 | 38 | 70 | 320 | 7.30/62/117/29.6 | ↓ FiO2 to 60% |
| 9 | AC/VC | 12 | 38 | 50 | 320 | 7.36/65/68/35.1 | None |
| 10 | AC/VC | 10 | 38 | 45 | 320 | 7.43/61/91/39.1 | None |
| 11 | AC/VC | 6 | 32 | 40 | 350 | 7.46/49/58/35.1 | ↑ FiO2 to 60%; ↑ PEEP to 8 cmH2O |
| 12 | AC/VC | 8 | 32 | 45 | 350 | 7.44/48/110/32.0 | ↓ FiO2 to 40%; ↓ PEEP to 6 cmH2O |
| 13 | PS | 6 | N/A | 30 | N/A | 7.46/42/71/29.0 | Extubated successfully to NC, 6 LPM |
[i] Abbreviations: paCO2 = partial pressure of arterial carbon dioxide (mmHg); paO2 = partial pressure of arterial oxygen (mmHg); HCO3 = concentration of bicarbonate within arterial blood sample (mMol/L); PEEP = positive end expiratory pressure (mmHg); bpm = breathes per minute; FiO2 = fraction of inspired oxygen; AC/VC = assist-control/volume-control; PS = pressure support; NC = nasal cannula; LPM = Liters per minute
1First day of intubation
2Ventilator changes made following corresponding ABG values. Repeat ABGs were not obtained because pulse oximeter readings revealed stable oxygen saturations following adjustments.
3First day proning was initiated to improve oxygenation & ventilation. Proning occurred in 16-hour intervals.
Table 3
Broncheoalveolar Lavage (BAL) Samples Collected on Day 5 of Hospital Course
| RBC | Nucleated Cells | Cell Differentials | |
|---|---|---|---|
| BAL #1 | 28000 | 388 | - Segs: 86% |
| - Lymphs: 1% | |||
| - Mono/Mcrphg: 8% | |||
| - Var Lymph: 1% | |||
| - Other: 4% | |||
| BAL #2 | 71000 | 406 | - Segs: 72% |
| - Bands: 3% | |||
| - Lymphs: 15% | |||
| - Mono/Mcrphg: 1% | |||
| - Eosins: 1% | |||
| - Other: 4% | |||
| BAL #3 | 76000 | 511 | - Segs: 70% |
| - Lymphs: 2% | |||
| - Mono/Mcrphg: 23% | |||
| - Other: 5% |
[i] Abbreviations: BAL = Bronchoalveolar Lavage; RBC = Red Blood Cells; Segs = Segmented Cells; Lymphs = Lymphocytes; Mono/Mcrphg = Monocytes/Macrophages; Var Lymph = Various Lymphocytes; Eosins = Eosinophils
Of Note: Trend of RBCs on sequential BALs led to the diagnosis of diffuse alveolar hemorrhage (DAH).
Table 4
Various Lab Studies Performed to Rule Out Infectious Etiology
| Infectious Agent | Type of Test | Source | Results |
|---|---|---|---|
| HIV 1,2 Ag/Ab | Polymerase Chain Reaction (PCR) | Serum | Non-reactive |
| Respiratory Viral Panel (RVP)1 | Polymerase Chain Reaction (PCR) | Nasal Swab | Not Detected |
| Legionella Antigen | Enzyme Immunoassay (EIA) | Urine | Negative |
| Q Fever Ab IgM/IgG (Phase I-Ii) | Indirect Immunofluorescence Antibody (IFA) | Serum | <1:16 |
| Coccidiodes Antibody | Immunodiffusion (ID) & Complement Fixation (CF) | Serum | Negative |
| Cocci Immunodiffusion IgM/IgG | Immunodiffusion (ID) | Serum | Negative |
| Quantiferon TB Gold | Interferon-Gamma (IFN-γ) Release Assay (IGFRA) | Serum | Negative |
| Hepatitis Panel2 | Polymerase Chain Reaction (PCR) | Serum | Non-reactive |
| Acid Fast | Culture | Sputum | No Growth Detected |
| Gram Stain | Culture | Blood & BAL3 | No Growth Detected |
| Viral | Culture | BAL | No Growth Detected |
| Respiratory | Culture | Sputum | No Growth Detected |
| Fungal Stain | Culture | Blood & BAL3 | No Growth Detected |
[i] Abbreviations: HIV = Human Immunodeficiency Virus; Ag = Antigen; Ab = Antibody; IgM = Immunoglobulin M; IgG = Immunoglobulin G; TB = Tuberculosis; BAL = Bronchoalveolar Lavage
1RVP consists of the following viral PCR test(s): Adenovirus, Metapneumovirus, Rhinovirus/Enterovirus, Influenza A&B, Parainfluenza 1-4, RSV, Bordetella parapertusis, RP, Bordetella pertussis, RP, Chlamydophila pneumoniae, Mycoplasma pneumoniae, RP, Coronavirus HKV1/NL63/229E/OC43
2Hepatitis panel consists of the following antibody (AB) and antigen (Ag) test(s): HAV AB IgM, HBC AB IgM, HBS AB, HBS Ag, & HCV AB
3Bronchoalveolar Lavage (BAL) samples as listed above under Table 2
Table 5
Studies Performed to Rule Out Autoimmune Cause
| Autoimmunity Tested | Type of Test | Source | Results |
|---|---|---|---|
| C-ANCA/P-ANCA AB1 | Enzyme Immunoassay (EIA) | Serum | Negative |
| Antinuclear Antibody (ANA) Panel2 | Indirect Immunofluorescence Antibody (IFA) | Serum | Negative |
| Angiotensin Converting Enzyme | Enzyme-Linked Immunosorbent Assay (ELISA) | Serum | 20 U/L (ref. range: 16-85 U/L) |
| C1 Esterase Inhibitor | Enzyme Immunoassay (EIA) | Serum | 60 mg/dL (ref. range 19 - 37 mg/dL |
| C1 Esterase Inhibitor, Functional | Enzyme Immunoassay (EIA) | Serum | > 90 (ref. range: > 67 (Normal) 41-67 (Equivocal) <41 (Abnormal)) |
| C2 Complement | Immunodiffusion (ID) | Serum | 63 u/mL (ref. range: 25 - 47 u/mL) |
| C5 Complement | Immunodiffusion (ID) | Serum | 34 mg/dL (ref. range: 10.6 - 26.3 mg/dL) |
[i] Abbreviations: AB = Antibody
1Antineutrophil Cytoplasmic Antibody (ANCA) testing includes: Anti-myeloperoxidase (MPO) antibodies & anti-proteinase 3 (PR3) antibodies
2ANA panel consists of the following antibody (AB) tests: ANA AB Quant, anti-CCP3 AB, anti-Centromere AB, anti-Chromatin AB, anti-RNP AB, anti-SCL-70 AB, anti-Sm AB, anti-SS-A AB, and anti-SS-B AB