Days

Interventions

Results

6/9/19

Assessed by surgeons and adduct abscesses were opened, swabs were taken for culture (Figure 1 and Figure 2)

Dead bodies were removed and instructions were given for daily changes. A buttock biopsy was taken for culture by the surgeons.

6/9/19

Bronchoscopy

BAL was obtained for PCR, Aspergillus, common, fungal, virological, cytological and AFBs. Patient intubated under sedation with propofol 20 ml/h - fentanyl 10 ml/h. edematous bronchitic mucosa with several whitish secretions was detected. Free stomata up to subsegmentals.

6/9/19

The patient in ac mode on the ventilator regarding low oxygen needs.

It revealed bilateral diffuse micro-nodular infiltrates in all lung fields. Viral panel, brucella test to vet services and immune check was sent.

6/9/19

CXR

6/9/19

Lasix QID to optimize diuresis and started clindamycin for possible granulomatous toxins.

From the cardiovascular system, noradrenaline requirements remained low with sinus tachycardia and positive balance.

10/9/19

1.                Buttock tissue 6/9/19: direct positive +3 for acid fast bacilli, PCR positive for TB, (S) on rifampicin

2.                BAL: immediate negative for acid fast bacilli, positive PCR for TB, (S) rifampicin

3.                Culture for common microbes from thigh tissue left: No growth

4.                Stop antibiotics for common germs

13/9/19

She is still not waking up, she received continuous administration of midazolam until 10/9/19 with creatinine clearance very low.

she shows satisfactory diuresis with continuous administration of furosemide

respiratorily, she has little need for a ventilator and does not need the administration of vasoconstrictors.

It most likely has a build-up in fat.

16/9/19

Abscesses on the thighs are often surgically cleaned with removal of necromata (Figure 3 and Figure 4)

had the dose of enoxaparin reduced due to decreased creatinine clearance and bleeding from the oral and nasal mucosa. She also had petechiae on the chest and abdomen.

17/9/19

During the clinical examination she opened her eyes to her name so the Glasgow scale from 3/15 became 5/15.

18/9/19

a chest X-ray was done and you present improved. worsening renal function had satisfactory diuresis with high doses of furosemide. Creatinine has plateaued at 5.5. With IV furosemide he had a negative balance every day.

19/9/19

Episode of desaturation and difficulty breathing. She had bloody discharge with duct obstruction. blood products were replenished and desmopressin was administered.

a ductal catheter was placed.

She started hemodialysis because even though she urinates, she doesn't do good dialysis, it raises urea and phosphorus.

A percutaneous tracheostomy was performed

AC mode with FiO₂ 45% (18/9/19 until 100%) and relatively good gas exchange.

Respiratory wheeze: Bilateral roughness, significant decrease in right APS. Repeat chest X-ray with base thickening almost right

Feverless

20/9/19

She completed 2 weeks of antituberculosis treatment and a sample of bronchial and abscess samples was sent for acid fast testing.

Due to a septic condition, the antibiotic treatment was escalated with the addition of tazobactam/piperacillin, vancomycin. Fresh bronchial secretions and tissue samples were obtained to check the success of antituberculosis treatment.

Addition of pyridoxine to protect against peripheral neuropathy.

27/9/19

Stenotrophomonas is detected from cultures

Treatment modification to TMP-SMX

30/9/19

Continuous hemodialysis stopped

was placed on IV furosemide

3/10/19

Surgical cleaning of thighs.

4/10/19

Mobilization out of bed and on automatic ventilation model - preparation for T-pieces tests

9/10/19

Resubmission of tissue cultures from thighs for classic culture (CLEAN WOUND)