Multiple drugs
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Multiple drugs Lack of efficacy: case report
A 70-year-old man exhibited lack of drug effect while being treated with epinephrine, norepinephrine, hydrocortisone, ringer’slactate and vasopressin for the treatment of hypotension [not all dosages and routes stated]. The man presented to the emergency department with the complaint of altered mental status. He was normal 2 days before presented to the emergency department. He had a rice cake made with potato, after that he experienced increased urinary frequency, decreased urine volume, he did not experience any other complications. His son noticed he was disoriented and when his son trying to speak to him, his eyes rolled back, and he fell to the floor. He was brought to the emergency department and was alert during that time. He had a history of benign prostatic hyperplasia, hypertension, and asthma. He was receiving amlodipine, enalapril and atenolol. His son reported that his father was a taxi driver and worked in sugarcane fields one or more times each week. He reported no insects bite, no consumption of raw food, or contact with saltwater or freshwater sources. He was a nonsmoker and occasional drinker. He underwent physical examination, and his face was flushed and oedematous. He had conjunctival injection in both the eyes. His pupils were equal, normal sized, and symmetrically responsive to the light. He also had multiple dental caries which were untreated. His cardiac and lung examination did not show any abnormalities. Rectal examination showed an enlarged, nontender prostate. No oedema was observed. Some superficial abrasions were observed on his right upper arm, no insects bite was observed. He underwent different laboratory tests which were normal. Sinus tachycardia was revealed by an ECG. Based on the lab tests, he was initiated infusions of sodium chloride [normal saline] and norepinephrine. A lumber puncture was performed, which revealed 10 red cells, 1 monocyte, a glucose level of 140 mg/decilitre, and a protein level of 37 mg/decilitre. No organism was found by gram’s staining of CSF, after that he started therapy with cefotaxime, clindamycin, and minocycline empirically to cover likely causes, including toxic shock syndrome and scrub typhus. The therapy continued with norepinephrine along with 4L of ringer’s-lactate [lactated Ringer’s solution]. He was admitted to the ICU. The next morning, he started therapy with vasopressin and epinephrine, but the hypotension persisted, with systolic BP (range 50-60 mmHg). He started 100mg of IV hydrocortisone, but no improvement of blood pressure was observed. He was found febrile; tachypnoea was noted. He was intubated, and continuous venovenous haemodyalysis was performed, and given the concern for an unidentified toxin or toxicant. He was maintained on veno-venous haemodyalysis for 3 days and his hypotension gradually resolved. At the same time, he developed desquamation in the face, palms, axillae, and genital area. His Blood, urine, and CSF cultures remained negative. Serologic tests for rickettsiosis
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