35-Year-Old Woman With Cough, Fever, and Anorexia

Abstract

A 35-year-old woman was admitted to the hospital with a 2-day history of increasing cough and chest congestion. Two days before admission, the patient noted the onset of sore throat, sinus congestion, and a worsening nonproductive cough. She reported having chills and fever coinciding with the onset of the cough. A review of systems was remarkable only for markedly diminished oral intake during the 48 hours before admission. The patient's medical history was notable for spinal muscular atrophy diagnosed at the age of 6 months and an episode of communityacquired pneumonia 2 years before the current admission. Her only medication was an enema once weekly to facilitate bowel movements, and she had no known drug allergies. Her family history was remarkable for 2 siblings who died in infancy secondary to spinal muscular atrophy. She denied alcohol, tobacco, or illicit drug use. On physical examination, the patient was afebrile, her pulse rate was 117/min, and her blood pressure was 79/43 mm Hg. Respirations were 12/min, and pulse oximetry revealed an oxygen saturation of 99% while the patient breathed room air. Her height and weight were 152.4 cm and 32.4 kg, respectively (body mass index, 14 kg/m 2). The patient appeared thin and had marked muscular atrophy but was in no acute distress. The mucous membranes appeared dry, and heart sounds were normal. Decreased inspiratory effort was noted, and bronchial breath sounds were heard at the base of the left lung. She had absent deep tendon reflexes and diffuse muscular weakness (proximal greater than distal). Findings on the remainder of her examination were unremarkable. Chest radiography revealed a left lower lobe infiltrate. Laboratory test results were as follows (reference ranges shown parenthetically): white blood cell count, 21.4 × 10 9 / L