A 20-year-old woman with insignificant medical history was referred to our emergency department from another hospital for vomiting, fever, and impaired consciousness with a tentative diagnosis of bacterial meningitis. She had taken an over-the-counter antihistamine for pollinosis. Her vital signs on arrival were as follows: blood pressure 175/84 mmHg, heart rate 134 b.p.m., respiratory rate 28 breaths/min with an oxygen saturation of 96% on room air, and body temperature 38.0°C. Her Glasgow Coma Scale was 11 (E4V1M6), and we could not detect any significant neurological signs such as weakness of her limbs. Her pupils were bilaterally dilated to 5 mm. No nuchal rigidity or other meningeal signs were observed. Laboratory tests revealed glutamic oxaloacetic transaminase 30 IU/L, glutamic pyruvic transaminase 14 IU/L, C-reactive protein 0.43 mg/dL, white cell count 17,180/μL, (band cells 6.4%, segmented cells 89.4%, lymphocytes 2.2%, and monocytes 1.8%), and PCT over 10 ng/mL. Urine test, chest X-ray, computed tomography of the head, and cerebrospinal fluid test showed normal findings. We initially suspected systemic bacterial infection because of her fever and impaired consciousness, which is why we tested PCT. Although the cerebrospinal fluid test was normal, we cannot completely rule out bacterial infection due to the PCT elevation; therefore, we started treatment with empiric antimicrobials. Gradually, her level of consciousness improved; she confessed that she had taken 100 tablets of an ephedrine extract (Lipodrene, Hi-Tech Pharmaceuticals. Inc., Norcross, GA, USA), which contains caffeine (10 g), theophylline (amount unknown), yohimbine (amount unknown), and ephedrine (2.5 g), intending to commit suicide. We speculated that her low Glasgow Coma Scale on arrival was due to selective mutism because she had suicidal ideation and mood disorders. Her general condition stabilized, and blood tests showed no aggravation. Blood and cerebrospinal fluid culture results were negative on day 4. The PCT level decreased to 0.32 ng/mL on day 5, and she was discharged from hospital on the same day.
A 70-year-old woman with a 9-year history of PD was admitted to the emergency department (ED) with a 1-day history of altered consciousness, fever, and convulsive movements. She was already bedridden (Hoehn and Yahr scale 5) and had left hand tremor. Her medications included carbidopa/levodopa (25 mg/100 mg per oral [PO] three times a day) and memantine (10 mg PO twice a day). Her family member informed us that she had taken her antiparkinsonian medications regularly before admission to the ED and that she had recurrent diarrhea with poor oral intake 1 week before the ED visit. After the recurrent diarrhea 1 week before the ED visit, the left hand tremor was aggravated. At admission, her vital signs included a blood pressure of 100/60 mmHg, temperature of 39.0°C, respiratory rate of 24 breaths/min, and heart rate of 138 beats/min. A physical examination showed hot and wet skin, rigidity of extremities, and left hand tremor. The patient showed seizure-like movements accompanied by leftsided eye deviation and muscle contraction 30 minutes after admission to the ED. The results of an arterial blood gas analysis showed respiratory alkalosis (pH 7.51, PaCO2 22 mmHg, PaO2 148 mmHg, and HCO3- 18.3 mEq/L) via O2 face mask 10 L. The initial laboratory results showed a white blood cell count of 16.2 × 103/L, sodium at 146 mEq/L, blood urea nitrogen (BUN) at 34.4 mg/dl, creatinine at 0.6 mg/dl, creatinine kinase(CK) at 41 U/L, and C-reactive protein (CRP) < 0.5 mg/dl. The computed tomography (CT) scan of the chest and abdomen did not show any abnormal findings. The brain CT showed severe brain atrophy with communicating hydrocephalus, but the cerebrospinal fluid examination result was normal. An electroencephalogram showed no epileptiform abnormalities. There were no cultured bacteria in the patient’s blood or urine. Six hours after admission, the patient showed high fever (> 40°C). The blood pressure of this patient was 90/50 mm/Hg despite administering 1.5 L of 0.9% NaCl over 4 hours. At 12 hours after admission, blood pressure was decreased (systolic blood pressure of 40 mmHg) and her respiration was shallow. Then, we decided intubation and mechanical ventilation support, and the patient was given a vasopressor (norepinephrine 0.6 μg/kg/h IV). Central venous catheterization was performed via the right subclavian vein and central venous pressure was 3 mmHg. To control the fever, dantrolene sodium (40 mg IV) and a cooling blanket were used; as a result, her temperature decreased to 36°C 15 hours after admission. At 14 hours after admission, the laboratory results indicated sodium at 149 mEq/L, BUN at 63.3 mg/dl, creatinine at 1.6 mg/dl, serum procalcitonin (PCT) at 25.63 ng/ml, and myoglobin at 970.8 ng/ml but showed no elevated CRP (). Based on a presumptive diagnosis of severe pseudomembranous colitis due to a history of antibiotic use (ceftriaxone 2 g for 5 days) 1 month before and elevated PCT, oral vancomycin was given once. Urine output was decreased (< 0.4 ml/kg/h), and hence, continuous venovenous hemodiafiltration (CVVHDF) with Multifiltrate® (Fresenius Medical Care, Bad Homburg, Germany) for acute kidney injury and oligouria was applied at 20 hours after admission. At 43 hours after admission, the laboratory results showed elevated CK (274 U/L) and decreased PCT levels (9.79 ng/ml). Clostridium difficile and its toxins were not detected in the stool and results of polymerase chain reaction assays were negative. There was improvement in the renal function tests and oligouria, so CVVHDF was stopped at 56 hours after admission. Based on a diagnosis of MS in PD on the 4th hospital day (HD), the patient received antiparkinsonian drugs that had been taken previously via a Levin tube. The frequency of the left hand tremor decreased, and her consciousness recovered to its previous condition. Weaning and extubation were performed on the 12th HD. After conservative treatment, she was discharged on the 22nd HD after recovery to her previous condition before admission.