17494815.ab.1 A 51-year-old {30525-0:Age:Patient:Qn:EMPTY(SCN=Age Patient)|51[years]} woman {21840-4:GenderType:Pt:Nom:EMPTY(SCN=none)|woman} with a history of hypertension {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|hypertension]} developed sudden confusion {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|confusion}, drowsiness {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|drowsiness}, and severe abdominal pain {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|pain} 4 days after undergoing clipping of an anterior communicating cerebral artery aneurysm. 

17494815.ab.2 Her social history {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|migraines} was significant for migraines and two abortions {29546-9:History of symptoms & diseases:Find:Pt:^Patient:Nar:Observed(SCN=none)|abortions}.

17494815.ab.3 Physical Examination: On physical examination {29545-1:Physical findings:Find:Pt:^Patient:Nar:Observed(SCN=none)|confused}, she was noted to be confused, agitated {29545-1:Physical findings:Find:Pt:^Patient:Nar:Observed(SCN=none)|agitated}, and in pain {29545-1:Physical findings:Find:Pt:^Patient:Nar:Observed(SCN=none)|in pain}. 

17494815.ab.4 Her respiratory rate {9279-1:Breaths:NRat:Pt:Respiratory system:Qn:EMPTY(SCN=Respiratory Rate)|30[breaths/min]} was 30 breaths/min, BP {55284-4:Blood pressure systolic & diastolic:Pres:Pt:Arterial system:Qn:EMPTY(SCN=BP sys/dias|90/60[mm Hg])} was 90/60 mm Hg, and heart rate {8867-4:Heart beat:NRat:Pt:XXX:Qn:EMPTY(SCN=Heart Rate)|125[beats/min]} was 125 beats/min.

17494815.ab.5 Her oxygen saturation {20564-1:Oxygen saturation:SFr:Pt:Bld:Qn:EMPTY(SCN=O2 % Bld)|96[%]} was 96% while breathing room air. 

17494815.ab.6 The findings of a cardiac examination {10200-4:Physical findings:Find:Pt:Heart:Nar:Observed(SCN=none)|normal|[no]murmur} were normal with no detectable murmur. 

17494815.ab.7 Her extremities {10196-4:Physical findings:Find:Pt:Extremities:Nar:Observed(SCN=none)|cold} were slightly cold with a mottled appearance of the skin {39104-5:Appearance:Aper:Pt:Skin:Nar(SCN=Appearance Skin)|mottled|Fishnet-like, nonblanchable, bluish-red discoloration surrounding a pale center on the lower limbs} (Fig 1). 

17494815.ab.8 Figure 1: Fishnet-like, nonblanchable, bluish-red discoloration surrounding a pale center on the lower limbs. 

17494815.ab.9 Laboratory Investigations: The hemoglobin {14775-1:Hemoglobin:MCnc:Pt:BldA:Qn:Oximetry(SCN=Hgb BldA Oximetry-mCnc)|normal{mg%]} and hematocrit {20570-8:Hematocrit:VFr:Pt:Bld:Qn:EMPTY(SCN=Hct Fr Bld)|normal[%]} were normal, while the WBC count {26464-8:Leukocytes:NCnc:Pt:Bld:Qn:EMPTY(SCN=WBC # Bld)|22,000[cells/µl]} was 22,000 cells/µL, with 8% band cells {26508-2:Neutrophils.band form/100 leukocytes:NFr:Pt:Bld:Qn:EMPTY(SCN=Neuts Band Fr Bld)|8[/100 leukocytes]} and platelet count {26515-7:Platelets:NCnc:Pt:Bld:Qn:EMPTY(SCN=Platelet # Bld)|94 x 109[cells/L]} of 94 x 109 cells/L.

17494815.ab.10 The concentration of serum HCO3 {1963-8:Bicarbonate:SCnc:Pt:Ser:Qn:EMPTY(SCN=HCO3 Ser-sCnc)|6[mmol/L]} was 6 mmol/L, sodium {2951-2:Sodium:SCnc:Pt:Ser/Plas:Qn:EMPTY(Sodium SerPl-sCnc)|115[mmol/L]} was 115 mmol/L, potassium {2823-3:Potassium:SCnc:Pt:Ser/Plas:Qn:EMPTY(SCN=Potassium SerPl-sCnc)|5.5[mmol/L]} was 5.5 mmol/L, and chloride {2075-0:Chloride:SCnc:Pt:Ser/Plas:Qn:EMPTY(SCN=Chloride SerPl-sCnc)|107[mmol/L]} was 107 mmol/L. 

17494815.ab.11 The concentration of creatinine {14682-9:Creatinine:SCnc:Pt:Ser/Plas:Qn:EMPTY(SCN=Creat SerPl-sCnc)|97 [mmol/L]} was 97 mmol/L, urea {3094-0:Urea nitrogen:MCnc:Pt:Qn:EMPTY(SCN=BUN SerPl-mCnc)|5[mmol/L]} was 5 mmol/L, and glucose {15074-8:Glucose:SCnc:Pt:Bld:Qn:EMPTY(SCN=Glucose Bld-sCnc)|10[mmol/L]} 6 was 10 mmol/L. 

17494815.ab.12 Serum lactate dehydrogenase {2532-0:Lactate dehydrogenase:CCnc:Pt:Ser/Pl:Qn:EMPTY(SCN=LDH SerPl-cCnc)|900 [U/L]} concentration was 900 U/L. 

17494815.ab.13 Serum lactic acid concentration {2524-7:Lactate:SCnc:Pt:Qn:EMPTY(SCN=Lactate SerPl-sCnc)|14[mmol/dL]} was 14 mmol/dL. 

17494815.ab.14 Coagulation studies {34714-6:Coagulation tissue factor induced.INR:RelTime:Pt:Bld:Qn:EMPTY(SCN=INR Bld Qn)|[/1]} revealed an international normalized ratio of 2 and an activated partial thromboplastin time {12185-5:Coagulation surface inducedTime:Pt:Bld^control:Qn:Coag(SCN=aPTT Bld Cont Qn)|45[sec]} of 45 s (normal range, 24 to 34 s). 

17494815.ab.15 Few schistocytes {800-3:Schistocytes:ACnc:Pt:Bld:Ord: Microscopy.light(SCN= Schistocytes Bld Ql Smear|few)} were noted on the peripheral blood smear. 

17494815.ab.16 Initial arterial blood gas analysis while the patient was breathing room air showed a PaO2 {2703-7:Oxygen:PPres:Pt:BldA:Qn:EMPTY(SCN=pO2 BldA Qn|90[mm Hg])} of 90 mm Hg, a PaCO2 {2019-8:Carbon dioxide:PPres:Pt:BldA:Qn:EMPTY(SCN=pCO2 BldA Qn)|19[mm Hg]} of 19 mm Hg, and a pH {28646-8:pH:SCnc:Pt:BldCoA:Qn:EMPTY(SCN=pH BldCoA-sCnc)|7.1} of 7.1. 

17494815.ab.17 The patient was treated for sepsis of unknown origin with placement of a central venous catheter, rapid fluid infusions, and therapy with piperacillin/tazobactam (Tazocin; Wyeth Pharmaceuticals; Madison, NJ), 4.5 g IV q8h. 

17494815.ab.18 The initial central venous pressure {8591-0:Intravascular mean:Pres:Pt:Venous.central:Qn:EMPTY(SCN=none)|6 [cm H2O]} was 6 cm H2O. 

17494815.ab.19 Therapy with IV hydrocortisone for adrenal insufficiency of sepsis (50 mg IV q6h) was also added in view of the septic picture with hyponatremia and hyperkalemia.

17494815.ab.20 The findings of her portable plain abdominal film {30763-7:Views AP & lateral crosstable portable:Find:Pt:Abdomen:Nar:XR(SCN=Abd XR AP+Lat Xtable port)|normal} were normal. 

17494815.ab.21 A CT scan of the abdomen {41806-1:Multisection:Find:Pt:Abdomen:Nar:CT(SCN=Abd CT)|shown in Figure 2} is shown in Figure 2. 

17494815.ab.22 A CT scan of the brain {24725-4:Multisection:Find:Pt:Head:Nar:CT(SCN=Head CT)|loss of gray matter/white matter differentiation on the right hemisphere compared to the left side} showed loss of gray matter/white matter differentiation on the right hemisphere compared to the left side, indicating an infracted middle cerebral artery territory. 

17494815.ab.23 An MRI of the brain {24590-2:Multisection:Find:Pt:Brain:Nar:MRI(SCN=Brain MRI)|multiple parenchymal hyperdense lesions}, which had been performed earlier, showed multiple parenchymal hyperdense lesions that were suggestive of vasculitis. 

17494815.ab.24 No echocardiogram was performed. 

17494815.ab.25 Figure 2: CT scan of the abdomen on ICU admission (arrows point to abnormalities). 

17494815.ab.26 When the patient returned from the radiology department, hypotension and respiratory failure with increasing dyspnea developed, which required intubation and mechanical ventilation. 

17494815.ab.27 Vasopressor therapy was initiated. 

17494815.ab.28 A chest radiograph {30745-4:Views:Find:Pt:Chest:Nar:XR(SCN=Chest XR)|bilateral diffuse infiltrates} showed bilateral diffuse infiltrates. 

17494815.ab.29 Therapy with activated protein C could not be used in view of her recent subarachnoid hemorrhage.

17494815.ab.30 During the next 2 h, the patient’s skin {39104-5:Appearance Skin:Aper:Pt:Skin:Nar:EMPTY(SCN=Appearance Skin)|mottled} became progressively mottled. 

17494815.ab.31 A repeat lactic acid {2524-7:Lactate:SCnc:Pt:Qn:EMPTY(SCN=LactateSerPl-sCnc)|12[mmol/dL]} measurement 2 h later revealed that the level were still high (12 mmol/dL).