Case Presentation
A 37-years-old, healthy, non-smoker male construction worker attended
our emergency department with a history of dry cough, fever, and
shortness of breath for three days. His respiratory rate was 20/min with
O2 Saturation of 94% on a nasal cannula 4 L/m, hypotensive on
norepinephrine, looked confused but obeyed commands.
Chest radiography showed Non-homogeneous opacities in the right mid and
lower zones. Arterial blood gas on admission revealed hypoxemia (PaO2 71
mmHg) and mild hypercapnia (PaCO2 43 mmHg), high bicarbonate
concentration (23.6 mmol/L) and pH was 7.366 with normal lactate.
Initially, he was started on broad-spectrum antibiotics. His oxygenation
maintained with Nasal canula initially. Subsequent ABGs showed elevation
PaCO2 and was supported with Bilevel positive airway pressure
ventilation (Bi-PAP) alternated with high flow nasal cannula. The
respiratory viral panel came positive for Rhinovirus PCR & Human
Metapneumovirus PCR, and septic workup were negative.
He improved clinically and weaned from norepinephrine for over 24 hours.
However, he continued to require BiPAP due to type 2 respiratory failure
with noted episodes of bradypnea (8-10 BPM) and dropped oxygen
saturation during sleep. Drug overdose was ruled out, and thyroid
functions were normal. He developed mild occasional difficulty of
swallowing on 6th day of hospital admission.
In view of persistent type 2 respiratory failure which is unexplainable
by pulmonary pathology and mild occasional difficulty of swallowing and
bradypnea Neurological evaluation was done showed absent gag reflex,
horizontal nystagmus, and wide base walking. Deep tendon reflexes ware
exaggerated with impaired sensation in lower limbs. Thin liquid- post
swallowing cough was noted, pain while swallowing, so feeding
nasogastric tube was inserted. MRI brain and Cervical Spine (see Fig 1
& Fig 2) was done, which revealed Arnold Chiari malformation with upper
cervical syrinx suggestive of a Type-I ACM with associated
cervico-medullary junction compression. The patient was transferred to
the Neuro-surgery Unit for surgical decompression with cervical
fixation.