A 27-year-old woman presents with sudden onset agitation and delirium. In the emergency department, she has incoherent speech and lashes out violently at staff. She is initially febrile (38.7ºC). She is admitted to the ICU for observation and after two days is intubated for deteriorating mental status. Prior to intubation, she is noted to have labile blood pressure alternating between hypertension and hypotension.
PMH/PSH: none known
Medications: none known
Allergies: none known
Social Hx: Lives alone, part-time student/barista, no tobacco or illicit drug use, never-smoker
Exposures: One pet cat, avid hiker (3-day backpacking trip in Oregon 1 week ago, swam in freshwater lakes)
Vital signs: Temp 101°F; HR 60-120 beats/min; RR 22 breaths/min; BP 80/40-170/100 mm Hg
General: intubated, sedated, does not follow commands
Heart: intermittently tachycardic (regular)
Abdomen: thin, nontender, no masses
Skin: no rashes
Neurologic: pupils reactive, normal reflexes, no voluntary movement
CT and MRI of the head (enhanced): normal
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Adapted from: A Barista With Autonomic Neuropathy and Delirium. Medscape. May 07, 2012