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Answers on p 762.
A 70 year old man was found collapsed and acutely breathless in his toilet and was rushed to the local accident and emergency department. On arrival he was found to be dyspnoeic and unconscious with a Glasgow coma scale of 3. He had a temperature of 35.8°C, pulse rate of 120 beats/min regular, and blood pressure 250/125 mm Hg. His respiratory rate was 28 breaths/min and oxygen saturations were 84% on a fractional inspiratory oxygen of 0.60. There were generalised widespread coarse crepitations in his chest and pink frothy sputum in his mouth. Both pupils were constricted and reacted poorly to light. He had generalised hypotonia, absent tendon reflexes, and unresponsive plantars. Accompanying relatives denied any past medical history or regular medication intake.
He was immediately intubated and ventilated by an anaesthetist. His arterial blood gases showed type I respiratory failure. His full blood count, urea and electrolytes, and glucose were normal. Serial electrocardiograms (ECGs) showed sinus tachycardia only and no signs of myocardial ischaemia. His creatine kinase and subsequent troponin-T were normal. He had emergency computed tomography of his head (fig 1), which showed a large parenchymal bleed in the right cerebral hemisphere with extension into both lateral ventricles and the third and fourth ventricles and resultant hydrocephalus. He also had chest radiography (fig 2).
What abnormalities are seen on the chest radiograph?
What is the most likely diagnosis?
What is the pathophysiology of this condition?
How would you manage this patient?