Case based discussions

Varun Sharma (VS): A morbidly obese (120 kg, body mass index 49) 43-year-old female presented to the Queen Elizabeth University Hospital Glasgow, obtunded and in acute respiratory distress. She had been bed or chairbound for 2 years due to chronic pain, primarily related to severe hidradenitis suppurativa (HS). Other past medical history included poorly controlled Insulin-dependent type 2 diabetes mellitus (glycated haemoglobin (HbA1c) level 107 mmol/mol on admission), asthma and non-alcoholic fatty liver disease. She reported a cough productive of large volumes of purulent, foul-smelling sputum and severe pain, particularly localised to the axillae and lateral chest walls. The patient was tachycardic (147 bpm), tachypnoeic and hypoxic. Oxygen saturations were recorded at 85% on air. Examination revealed accessory muscle use, reduced air entry, dullness to percussion and bronchial breathing at the right lung base. The patient did not tolerate a full skin examination due to pain, and reported multiple drug allergies, including suxamethonium and metronidazole, but no penicillin allergy. Treatment for probable community-acquired pneumonia was initiated (intravenous amoxicillin and oral clarithromycin) pending chest radiography. Initial laboratory investigations revealed a C reactive protein level over 300 mg/L and marked hypoalbuminaemia (14 g/L). Over the next few hours, the patient reported facial swelling. On repeat clinical assessment, no stridor or airway compromise was noted. Antibiotic allergy was suspected, and intravenous hydrocortisone and chlorphenamine were administered. However, her facial swelling worsened and a chest radiograph, acquisition of which has been delayed, revealed significant …