Correct!
3. Respiratory distress, neurologic changes, and rash
The classic triad of symptoms in FES includes respiratory distress, neurologic changes, and a petechial rash. Symptoms typically present 24 to 72 hours after a trauma, with an insidious onset of dyspnea and hypoxemia. Neurologic symptoms follow the pulmonary complaints in up to 80% of patients. Commonly, patients develop confusion and agitation, which can progress to focal deficits with upper motor neuron signs, focal seizures, and coma (1,4). Unresponsiveness can be the initial presentation (4). The classic petechial rash occurs only in 20 to 50% of patients. Interestingly, the rash in FES is only found anteriorly on the body in nondependent areas (1). In Duran’s review of the 15 reported cases of liposuction-related FES, symptoms began at a mean of 25.6 hours after the start of surgery, with the most common presentation being dyspnea (10/15 patients), followed by fever (7/15 patients) and altered consciousness (6/15 patients) (6).
There are no validated diagnostic criteria for diagnosing FES, and diagnosis is primarily clinical. For cerebral fat emboli syndrome specifically, head CT is often normal (3). MRI typically shows diffuse hyperintense punctate lesions (“starfield pattern”) within the white and deep gray matter on diffusion-weighted and T2-weighted images (7,8).
Interestingly, there are no reports in the literature of acute liver failure in fat emboli syndrome. It is possible that our patient developed shock liver due to intra-operative hypotension, septic shock or an anesthetic drug reaction that was entirely unrelated to her fat emboli syndrome. Her liver abnormalities resolved with supportive care measures.
At this point, the patient is hemodynamically stable and is on minimal ventilator settings, but is unable to wake up.
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