Jessica L. Bunin, MD; Christopher J. Lettieri, MD


April 08, 2011

Clinical Presentation

A 26-year-old man, a soldier deployed to Afghanistan, was found in his barracks room unresponsive, pulseless, and cyanotic. Cardiopulmonary resuscitation was initiated immediately. Severe airway edema was noted, prompting emergency cricothyroidotomy. Resuscitative efforts resulted in return of spontaneous circulation, and he was transferred to the nearest medical treatment facility.

The soldier was unresponsive and pulseless for an unknown period of time.

History and Physical Examination

The patient's history and physical examination revealed the following:


  • Medical history: Previously healthy, no recent illnesses

  • Habits: No alcohol, no drugs, used smokeless tobacco regularly

  • Medications: None, no over-the-counter supplements

  • Ill contacts: None known

Physical Examination

  • General: Unresponsive upon presentation

  • Vital signs: Blood pressure 159/84 mm Hg, pulse 84 beats per minute; core temperature 99.1° F

Labs and Imaging

  • Evidence of transaminitis and acute kidney injury

  • Aspartate aminotransferase: 203 U/L; alanine transaminase: 350 U/L

  • Blood urea nitrogen: 66 mg/dL

  • Creatinine: 10 mg/dL

  • Serum lactate: 13 mmol/L

  • Arterial blood gases: pH 6.9, pCO2 55 mg/Hg, pO2 90 mmHg, HCO3 11 mmol/L, with oxygen saturation 89%

  • Rhabdomyolysis confirmed - creatinine phosphokinase: 21,000 U/L

  • Urinary drug screen: Negative

  • Toxicology screen: Negative

  • Chest x-ray: Left mid-lung field consolidation

  • CT head without contrast: Normal

Supportive care was continued, and the soldier was transferred through the levels of military medical care and evacuated to a military hospital in the United States 3 days after his initial presentation. Upon arrival, he was noted to be anuric with worsening pulmonary, hepatic, and renal function. Renal replacement therapy was initiated, and a repeat chest x-ray was notable for bilateral alveolar infiltrates consistent with acute respiratory distress syndrome.

The patient's renal function improved and he was weaned from mechanical ventilator support. He developed chronic neurogenic pain but, otherwise, he recovered fully. Following a prolonged intensive care unit stay, he was discharged to a long-term rehabilitation facility.


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