The patient was admitted to the medical intensive care unit. Her respiratory
and hemodynamic status deteriorated rapidly, and she was immediately intubated
because of tachypnea, respiratory distress, and oxygen desaturation. Frothy
pink secretions were suctioned from the endotracheal tube. Pulmonary artery
catheterization revealed right atrial pressure of 4 mm Hg (reference range,
0-6 mm Hg), right ventricular pressure of 17/5 mm Hg (reference range, 20-30/0-5
mm Hg), and pulmonary artery pressure of 20/10 mm Hg (reference range, 20-30/5-15
mm Hg), but pulmonary artery wedge pressures could not be measured. After
unsuccessful crystalloid resuscitation, vasopressor therapy (norepinephrine,
phenylephrine, and, later, vasopressin) was initiated. The differential diagnosis
included dissecting ascending aortic aneurysm with leakage, severe community-acquired
pneumonia, vasculitis (Wegener granulomatosis), and inhalational anthrax.
Rifampin, 300 mg intravenously every 8 hours, and clindamycin, 800 mg every
8 hours, were added to the antibiotic regimen, and the levofloxacin dosage
was increased to 500 mg every 12 hours.