medical case

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Healthy man goes camping—lands in ICU for 40 days with respiratory failure

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It was a diagnostic challenge, and doctors began reviewing the list of possibilities that could match his condition. The first guess of pneumonia could explain some of his respiratory findings, but he didn’t have a cough, had tested negative for common respiratory pathogens, and the lung imaging didn’t quite fit, making it seem unlikely. Blood cancers, such as polycythemia vera, might be able to explain the high concentrations of blood cells. And it might also make him more vulnerable to opportunistic lung infections, like a fungal infection that could explain the halo sign. But blood cancers were also deemed unlikely given that he didn’t have enlarged organs, which is often seen with such conditions. Another possibility was pulmonary–renal syndrome, but that also didn’t line up with the man’s case.

Diagnosis

There was one other possibility that seemed to tick all the boxes: fever, gastrointestinal symptoms, low oxygen saturation, pulmonary edema, and shock—a hantavirus infection.

Hantaviruses are RNA viruses that infect rodents worldwide. They typically cause asymptomatic, chronic infections in the animals, which spread the virus widely into their environments through their urine, feces, and saliva. Humans get infected when virus particles from rodent-contaminated areas are stirred up into the air and inhaled or through direct contact with the virus via the eyes, nose, mouth, or cuts.

In humans, the viral infection is anything but asymptomatic. While the disease mechanism isn’t entirely understood, the virus appears to be able to modulate immune responses in humans, causing blood vessels and capillaries in various places in the body to start leaking plasma. This leads to fluid building up in the lungs (the pulmonary edema) and systemic circulatory collapse.

A cardiopulmonary hantavirus infection typically has four stages: the incubation period, which can last up to 45 days after virus exposure; a prodromal phase of up to 12 days, which is marked by fever, fatigue, and pains; the cardiopulmonary phase, where breathing trouble, low oxygen saturation, and shock can develop; then, if you make it, the fourth stage, in which respiratory symptoms improve, but there’s lingering fatigue and the kidneys make abnormally large amounts of urine.

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The puzzling case of a baby who wouldn’t stop crying—then began to slip away

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A studio portrait of a crying baby.

Enlarge / A studio portrait of a crying baby.

It’s hard to imagine a more common stressor for new parents than the recurring riddle: Why is the baby crying? Did she just rub her eyes—tired? Is he licking his lips—hungry? The list of possible culprits and vague signs, made hazier by brutal sleep deprivation, can sometimes feel endless. But for one family in New England, the list seemed to be swiftly coming to an end as their baby continued to slip away from them.

According to a detailed case report published today in the New England Journal of Medicine, it all started when the parents of an otherwise healthy 8-week-old boy noticed that he started crying more and was more irritable. This was about a week before he would end up in the pediatric intensive care unit (PICU) of the Massachusetts General Hospital.

His grandmother, who primarily cared for him, noticed that he seemed to cry more vigorously when the right side of his abdomen was touched. The family took him to his pediatrician, who could find nothing wrong upon examination. Perhaps it was just gas, the pediatrician concluded—a common conclusion.

Rapid decline

But when the baby got home from the doctor’s office, he had another crying session that lasted hours, which only stopped when he fell asleep. When he woke, he cried for eight hours straight. He became weaker; he had trouble nursing. That night, he was inconsolable. He had frantic arm and leg movements and could not sleep. He could no longer nurse, and his mother expressed milk directly into his mouth. They called the pediatrician back, who directed them to take him to the emergency room

There, he continued to cry, weakly and inconsolably. Doctors ordered a series of tests—and most were normal. His blood tests looked good. He tested negative for common respiratory infections. His urinalysis looked fine, and he passed his kidney function test. X-rays of his chest and abdomen looked normal, ultrasound of his abdomen also found nothing. Doctors noted he had high blood pressure, a fast heart rate, and that he hadn’t pooped in two days. Throughout all of the testing, he didn’t “attain a calm awake state,” the doctors noted. They admitted him to the hospital.

Four hours after he first arrived at the emergency department, he began to show signs of lethargy. Meanwhile, magnetic resonance imaging of his head found nothing. A lumbar puncture showed possible signs of meningitis—high red-cell count and protein levels—and doctors began courses of antibiotics in case that was the cause.

Six hours after his arrival, he began losing the ability to breathe. His oxygen saturation had fallen from an initial 97 percent to an alarming 85 percent. He was put on oxygen and transferred to the PICU. There, doctors noted he was difficult to arise, his head bobbed, his eyelids drooped, and he struggled to take in air. His cry was weak, and he made gurgling and grunting noises. He barely moved his limbs and couldn’t lift them against gravity. His muscles went floppy. Doctors decided to intubate him and start mechanical ventilation.

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