De Bels et al. Journal of Medical Case Reports 2012, 6:20 http://www.jmedicalcasereports.com/content/6/1/20 Our patient developed a fever of up to 40°C seven days earlier and a non-productive cough three days later. He had not received any antimicrobial treatment prior to his hospitalization, the diagnosis of his primary care physician being influenza (A/H1N1v), given the ongoing outbreak. His medical history was remarkable for possible viral pericarditis without any consequence in 2007 and a gas- tric ulcer 30 years earlier. He had no drinking habits. He did not smoke cigarettes. He had not travelled abroad recently. He did not have any bird or pet. On hospital admission, our patient was in acute respiratory distress. His respiratory rate was 40 breaths/ minute, his temperature 38.3°C, his pulse 98 beats/min- ute and his blood pressure 114/60 mmHg. Auscultation revealed crackles over his whole left lung and over his right lower lung field. A computed tomography scan showed diffuse alveolar type infiltrates in his two lung fields with air bronchograms (Figure 1). Arterial blood gas analysis (under 100% oxygen through a non-rebreathing mask) showed pH 7.54, a partial pressure of carbon dioxide (PaCO2) 44 mmHg, partial pressure of oxygen (PaO2) 38 mmHg and an arterial blood oxygen saturation of 84%. His white blood cell count was 5780 cells/μL (86% neutrophils) and the erythrocyte sedimentation rate was 92 mm/h. Page 2 of 6 Laboratory values showed serum creatinine at 1.7 mg/ dL, potassium at 2.8 mEq/L, creatine phosphokinase at 644 IU/L, liver test alterations (alanine transaminase at 87 IU/L), lactate dehydrogenase elevation (1708 IU/L) and D-Dimers at 7420 ng/mL, activated partial throm- boplastin time of 72 seconds, normal international nor- malized ratio and blood platelets at 166.000/μL. His urine output was 0.4 mL/kg/h over six hours. An elec- trocardiogram showed a sinus tachycardia with a com- plete right bundle branch block. Serum samples obtained every week as from the day of admission showed a clear-cut seroconversion for C. pneumoniae antibodies (the course of the antibody titers shown in Table 1). Paired serum samples and antigens against the most common microorganisms, including atypical bacteria and common viruses such as A/H1N1v, were negative. Blood, sputum and urine tests for bacterial cultures obtained during the first day of hospitalization were negative. Our patient was treated by amoxycillin-clavulanic acid, moxifloxacin and oseltamivir. His respiratory status necessitated endotracheal intubation and mechanical ventilation. Severe arterial hypotension prompted nore- pinephrine infusion and the insertion of a pulmonary artery catheter. The initial hemodynamic pattern was Figure 1 Unenhanced computed tomography scan through the thorax showing alveolar type infiltrates of the two lung field with air bronchograms.