A 47-year-old male postal worker who worked in the mail-sorting area developed nausea, abdominal pain, and flulike symptoms. He attributed his symptoms to food poisoning and continued to work despite ongoing symptoms. Over the next several days he developed worsening nausea, vomiting, and abdominal pain and profuse sweating. On Day 5, while in church, he had a brief, self-limited syncopal episode. By the time paramedics arrived, he felt better. He went home, did not eat, and immediately went to bed. At 2 am on Day 6, while at work, he developed worsening nausea, vomiting, abdominal pain, and profuse sweating. He then drove himself to the emergency department.
In the emergency department, the patient’s temperature was 36.1°C (96.9°F), blood pressure was 82/59 mm Hg, pulse 95/min, respirations 18/min, and oxygen saturation 99% in room air. Physical examination was unremarkable. Laboratory data revealed mild leukocytosis and hemoconcentration. Chest radiograph showed a subtle and ill-defined area of increased density in the right subhilar region.
The following day his wife found him slumped in the bathroom. He was taken to a hospital by ambulance. On arrival, he reports nausea, vomiting, and lightheadedness. He denies dyspnea or chest pain but is ill-appearing and in respiratory distress. His vital signs are temperature 35.5°C (95.9°F), blood pressure 76/46 mm Hg, pulse 152/min, respiratory rate 28/min, and oxygen saturation 96% in room air. (Reported in JAMA. 2001;286:2554-2559.)
John H. Beigel, MD Christian Sandrock, MD, MPH