A 51 year-old woman with fistulizing Crohn's disease (on infliximab and prednisone; TPN-dependent) is currently admitted to the medical ICU for management of acute renal failure and fungal endopthalmitis. She had originally been transferred one day prior after a one-week stay at an OSH for a Crohn's flare. She had been having fatigue and generalized weakness and had a mild lactate elevation. She was treated for a presumed UTI. She later became septic, developing septic shock, leukocytosis, and an AKI. CXR demonstrated diffuse patchy opacities. One blood culture was positive for CONS. At this point, she was transferred to the MICU. She remains intubated. Sedation was held upon arrival. She otherwise has not been reactive to vocal or noxious stimuli. She's now receiving stress-dose steroids due to two-pressor distributive shock.
On day 2 of her admission here, she has remained persistently encephalopathic, unresponsive to stimuli. The MICU has also noted her pupils to be fixed and dilated. They obtained a non-contrast head CT. At this point, you are consulted while on call overnight. You get on your way to see the patient as you just finished up seeing your tenth ED consult of the night.
Fixed and dilated pupils? Well that can't be good. The localization is already apparent-- something affecting the midbrain, whether by direct compression or infiltration. With such a bad finding, it's reasonable to engage that type 1 thinking and algorithmically jump to the catastrophic processes that could have occurred or is occurring.
You're already wondering about any large hemorrhage or lesion with mass effect that could be compressing the midbrain, whether directly or indirectly (via ventriculomegaly and the resultant hydrocephalus). You're also likely wondering if they had been giving any medications that would cause this (including anything nebulized that might've leaked out and contacted her eyes). Oh, and you remind yourself to ask the primary team if ophthalmology had pharmacologically dilated her pupils recently as part of their examinations.
And how long has this finding been apparently? Unclear. If it was a sudden finding, then that's helpful to know, as any interventions for anything structural would have a higher likelihood of being effective.
As you rush up the stairs, you quickly pull up the non-contrast head CT that the MICU just got. Whew. There doesn't seem to be any large structural etiology at play here-- there's no large hemorrhage, there's plenty of space around the brainstem, and there's no ventriculomegaly. You relax a little. Could this just be from the large amounts of sedation he had been getting at the OSH?
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