A Shocking Development

A CLINICAL PROBLEM-SOLVING article by Joshua Levenson from University of Michigan, Ann Arbor.
A 20-year-old female college student presented in the winter with a 2-week history of fatigue, cough, sinus congestion, and rhinorrhea, followed by 2 days of vomiting, diarrhea, and abdominal pain.
The patient was brought to an urgent care center for evaluation. At that time, she reported abdominal pain related to emesis but said she had no dyspnea, chest pain, fever, or chills.
The pulse was 130 beats per minute, and systolic blood pressure ranged from 60 to 70 mm Hg. Emergency medical services were called, and 2 liters of normal saline were administered while the patient was being transported to the emergency department of a local hospital. On arrival, the oral temperature was 34.7°C, pulse 126 beats per minute, blood pressure 99/52 mm Hg, respiratory rate 18 breaths per minute, and oxygen saturation 100% while she was breathing ambient air. Cardiac examination revealed a regular tachycardia without extra heart sounds.
This patient contracted an acute, influenza-like illness, along with members of her family, and while the others recovered, her condition rapidly deteriorated. In a young person with a febrile illness and severe hypotension, the differential diagnosis is broad and must be addressed quickly, given the potentially catastrophic consequences. Any diagnostic evaluation must proceed in tandem with appropriate life-saving measures that include hemodynamic support.