Muscle Weakness Acquired in the Intensive Care Unit: Case Report

Introduction: Intensive Care Unit-Acquired Weakness (ICUAW) is a growing problem, associated with a longer duration of mechanical ventilation, greater permanence and in-hospital mortality. Preventing its risk factors, therefore, becomes fundamental in the approach to the critical patient. Case Presentation: A 45 year-old male, with no known previous comorbidities, but acromegalic phenotype, presented pale, dehydrated, hypotense and tachycardic with consciousness fluctuations to the emergency service. Investigation pointed to Diabetic Ketoacidosis (DKA) and hypokalemia. The patient underwent neuroimaging studies and Magnetic Resonance (MRI) showed a pituitary macroadenoma with suprasellar invasion. Growth Hormone (GH) and IGF-1 (Insulin Growth Factor-1) levels were increased and diagnosis of acromegaly was then established. In the fifth day there was a peak of Creatine Kinase (CK) with progressive decrease. After 12 days of hospitalization, with resistant hyperglycemia, proximal flaccid tetra paresis and global hyporeflexia (MRC score of 40 points) was noted. Clinical diagnosis of Critical Illness Myopathy (CIM) was established. After 30 days of hospitalization, he was discharged with MRC score of 50 points and improves in CK levels. Discussion: The presented case shows a CIM, a type of ICUAW. Some important risk factors are endocrine logical (thyroid diseases, diabetes, adrenal and pituitary dysfunctions). The patient presented hyperglycemia and underwent a prolonged period of hospitalization and use of glucocorticoid medications, increasing the risk of the disease. With clinical management and physiotherapy the patient regained autonomy. Conclusion: ICUAW can bring long-term consequences, so that early identification and management as well as preventive measures are primordial to minimize chronic disability and morbidity. Gustavo Piech Ricardo1*, Lohana Santana Almeida da Silva2, Marina Trombin Marques2, Berenice Cataldo Oliveira Valerio2, Nilza Maria Scalissi1, José Viana Lima Junior1, Francisco Tomaz Meneses de Oliveira2 and João Eduardo Nunes Salles1 1Department of Endocrinology and Metabolism, Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil 2Department of Neurology, Irmandade da Santa Casa de Misericórdia de São Paulo, Brazil Gustavo Piech Ricardo, et al., Clinical Case Reports International Endocrinology Remedy Publications LLC. , | http://clinicalcasereportsint.com/ 2020 | Volume 4 | Article 1181 2 to an intravenous insulin pump, after correction of hypokalemia. Due to the fluctuation in consciousness, the patient underwent a cranial tomography, showing a lesion in the pituitary topography, progressing the investigation with Magnetic Resonance (MRI), which showed a Pituitary Macro adenoma with suprasellar invasion, compressing optical chiasma, measuring in its largest axis 6.1 cm. Pituitary hormone measurements were performed: GH>200 mcg/L, IGF-1 476 ng/mL (RV 112 to 282), Prolactin 21 mcg/L (RV up to 24), ACTH 28p g/mL, Basal cortisol 23 mg/dL (RV>15), TSH 1.2 mUI/L (RV 0.45 to 4.5) and free T4 0.5 ng/dL (RV 0.6 to 1.3). Diagnosis of Acromegaly due to hormonal changes, lesion in adenohypophysis and suggestive phenotype. Treatment with a somatostatin analogue (Octreotide) 20 mg monthly was started, in addition to a dopaminergic agonist (Cabergoline) 1.5 mg/week. One day after admission, the patient evolved with a decrease in the level of consciousness requiring Orotracheal Intubation (OTI). He maintained high sodium levels, but already improving DKA. He was kept under OTI for 4 days, being extubated after normalization in sodium levels. The patient refused the surgical procedure for the treatment of acromegaly. He remained with difficult glycemic control during the period of hospitalization, with improvement in intra hospital glucose levels after about 15 days of admission, using high doses of insulin (2 ui/kg/day). He also received treatment with corticosteroids (hydrocortisone 300 mg/day for 8 days, followed by prednisone 40 mg/day for 18 days) due to the airway infection associated with the condition (sinusitis). After 12 days of hospitalization, a picture of flaccid tetra paresis of proximal predominance (total MRC score of 40 points), associated with global hyporeflexia, without changes in cranial nerves, sensitivity or in other modalities on neurological examination, was noted. Cerebrospinal fluid was normal. On the fourth day of hospitalization, he presented a Creatine Kinase (CK) of 12665, with a peak on the fifth day of 12888, followed by a gradual decrease during hospitalization. In the two weeks following extubation, the patient showed progressive clinical improvement in the peripheral nervous system, especially after better glycemic control. Due to the presence of generalized muscle weakness after severe, diffuse, symmetrical, flaccid pattern and without involvement of cranial nerves, associated with a sum of MRC less than 48 points, a diagnosis of myopathy of the critically ill patient was then established. At the time of hospital discharge, 30 days after admission, the patient had a sum of the MRC score of 50 points, good glycemic control, using insulin, improvement in CPK, creatinine and sodium levels. Maintained GH 195 mcg/L (RV<1) and with refusal of surgical procedure. Referred to the endocrinology clinic to follow up on the diagnoses of acromegaly and diabetes; and the neurology outpatient clinic for follow-up of the diagnosis of myopathy. Given the current epidemiological context, we emphasize that throughout the hospitalization period, the patient did not show any signs or symptoms suggestive of COVID-19 infection.