5. All of the above

Most severely ill patients in this age group would have an infectious etiology but the lack of fever or any prodrome are unusual. Blood and sputum cultures were obtained but showed no growth of pathogens. Bronchoscopy with bronchoalveolar lavage was performed which did not demonstrate a pathogenic organism. A friable edematous airway were noted without evidence of alveolar hemorrhage.

Although the normal BNP argues against heart failure, a bedside echocardiography was performed which showed normal chamber sizes and cardiac function.

Antibiotics were quickly de-escalated and the patient improved under supportive care. His chest x-ray cleared quickly (Figure 2).

Figure 2. Chest x-ray taken 7 days after admission.

He was discharged with a diagnosis of adult respiratory distress syndrome of unknown etiology. However, 22 months later he presented to another hospital with a very similar course but also developed acute kidney injury which required several episodes of hemodialysis. Again, he rapidly improved with supportive therapy and there was no apparent residual lung or kidney injury.

Ten months later he had a similar presentation. He again required mechanical ventilation. On the third day of admission, the patient’s roommate presented to the critical care team vials of a liquid substance he had said he had witnessed the patient inhaling prior to the onset of his illness (Figure 3).

Figure 3. Vials which patient’s roommate said he had inhaled.

Which of the following is contained in the vial? (click on the correct anser to proceed to the third of six pages)

  1. Cocaine
  2. Isobutyl nitrite
  3. Mexican chalea
  4. Peyote
  5. Synthetic cannabinoids

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