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A Pregnant Woman with Fever and Respiratory Failure

Case Editor - Judd Flesch

Reviewed By Microbiology, Tuberculosis & Pulmonary Infections Assembly

Submitted by

Sonia Vishin, MD


Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Jody Hunt, MD


Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Keith Wille, MD

Associate Professor

Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Submit your comments to the author(s).


A 28-year-old white female at 29 weeks gestation, G2P1, presented to the emergency department with increasing shortness of breath and fever for 3 days. She also endorsed nausea, loose bowel movements and emesis for 2 days prior to admission. Prior to this, she was in her usual state of health. She denied cough, chest pain, joint pain, rash or hemoptysis. Her past medical history was significant for well-controlled asthma. However, over the last few days, she had been using her rescue inhaler up to 8 times a day. She denied any sick contacts. She had one previous full-term pregnancy and delivered vaginally, with no complications. Her family history was significant for both parents having hypertension and diabetes mellitus. Her father also had congestive heart failure. The patient smokes one pack of cigarettes per day but denies alcohol or illicit drug use. She is married and lives with her husband and child. Her medications at the time of admission included folic acid, prenatal vitamins, fluticasone/salmeterol and albuterol MDI as needed.

Physical Exam

On examination, the patient’s pulse was 94 beats per minute and regular. She had a temperature of 101.3 degrees Fahrenheit and a blood pressure of 98/31 mm Hg. Her oxygen saturation was 84% on 100% O2 by nonrebreather mask and had a respiratory rate of 32 breaths per minute. Cardiovascular exam revealed no murmurs. Respiratory exam showed bilateral crackles. Abdominal exam showed gravid uterus, otherwise unrevealing.


  • Serum chemistries were significant for a bicarbonate level of 18 mEq/L and creatinine of 1.5 mg/dl
  • Complete blood count was significant for WBC 12.5 x 103, platelet count 145 x 103, hemoglobin 9.4 g/dl. Differential count was 90% segmented neutrophils and 8% lymphocytes
  • Urinalysis showed 3+ blood, 1+ ketones, 1+ protein
  • Liver function profile was significant for AST 148, ALT 32
  • Rapid flu test was negative

Chest radiograph is shown in Figure 1.

She was intubated urgently for respiratory failure.  Based on the chest radiograph and lab studies, further work up was done, including bronchoscopy with bronchoalveolar lavage (BAL):

  • BAL fluid:
    • CMV culture negative
    • Viral culture negative
    • Viral respiratory panel positive for Influenza A
    • Legionella culture negative
  • Blood cultures negative
  • Urine Legionella antigen negative
  • Transthoracic echocardiogram – bilateral ejection fractions >55%, no vegetations, no significant valvular disease


Figure 1. Portable chest radiograph

Question 1

What is the most likely diagnosis?


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