May 2013 Critical Care Case of the Month: Not an Air-Filled Sac
Thursday, May 2, 2013 at 11:13AM
Rick Robbins, M.D. in Pneumocystis jiroveci, non-AIDS, pneumocystis, trimethoprim/sulfamethoxasole, upper gastrointestinal bleeding

Lewis J. Wesselius, MD


Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ


History of Present Illness

A 66 year old woman presented to outside hospital with hematemesis and hematochezia. She was intubated for airway control and received 4 units of packed red blood cells. She was transferred to the Mayo Clinic Arizona due to an inability to control her upper gastrointestinal bleeding. During her transfer she required vasopressors.


She has a history of hepatitis C with cirrhosis and esophageal varices. In addition, she was diagnosed with a B-cell lymphoma 3 months prior to admission and had received 3 cycles of rituximab, cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin® (vincristine) and prednisone (R-CHOP).  

Physical Examination

She was intubated and receiving oxygen at a FiO2 of 0.4.

Vital signs: P 100 beats/min; B/P 113/78 mm Hg; Afebrile; R 20 breaths/min; SpO2 99%

Chest: clear to auscultation.


Her hemoglobin was 9.3 g/dL and her hematocrit was 29%.


Her admission chest x-ray is shown in Figure 1.

Figure 1. Admission portable chest-x-ray.

Which of the following should be done initially?

  1. Bronchoscopy with bronchoalveolar lavage
  2. Endoscopy
  3. Administer octreotide to control hypotension
  4. Administer 2 units of packed red blood cells to stay ahead of the bleeding
  5. All of the above

Reference as: Wesselius LJ. May 2013 critical care case of the month: not an air-filled sac. Southwest J Pulm Crit Care. 2013;6(5):209-17. PDF

Article originally appeared on SOUTHWEST JOURNAL of PULMONARY & CRITICAL CARE (
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