A 41-year-old African American male with no known PMH presented to our hospital with confusion and shortness of breath. On admission he was noted to have a blood pressure of 170/110, pulse of 120, respiratory rate of 26, and a pulse oxygen saturation of 98% on 100% non-rebreather. He required intubation in the emergency department for worsening respiratory and mental status, he was initially sedated with propofol. On physical examination, patient was 183 cm in height and 96.7 kg in weight with a BMI of 28. His pulmonary exam was pertinent for coarse breath sounds in right lower lung field, his neurologic exam was non-focal, he had no muscle tenderness or swelling, and skin examination did not show any rashes or lesions.

Initial laboratory findings showed a white blood cell count of 20.3 &times; 103 cells/ul with 83% neutrophils and 7% bands, hemoglobin of 13.6 &times; 103 cell/ul, platelet count of 170 &times; 103 cells/cubic mm, sodium of 126 mmol/L, potassium of 3.5 mmol/L, chloride of 88 mmol/L, bicarbonate of 11 mmol/L, BUN of 54 mg/dL, creatinine of 7.8 mg/dL, glucose of 158 mg/dL, calcium of 5.7 mg/dL, LDH of 6910 IU/L, creatine kinase of 370,000 U/L, AST of 2290 IU/L, and ALT of 374 IU/L. Chest radiograph showed a right lower lobe airspace opacity (Figure 1). His electrocardiogram showed sinus tachycardia with left atrial enlargement. He was started on broad spectrum antibiotics with vancomycin, cefepime, and metronidazole and was admitted to the intensive care unit

Over the next 48 hours, his CK level continued to rise peaking at 780,000 U/L despite aggressive IV fluid replacement. His kidney function continued to decline, and he ultimately required continuous renal replacement therapy. His echocardiography showed moderate left ventricular hypertrophy with a hyperdynamic left ventricular ejection fraction. Comprehensive infectious work up, including HIV, was negative except for positive urine legionella antigen. On day 2 of admission triglycerides levels went up to 1883 mg/dL. His lipase levels were noted to be elevated at 147. Sedation was switched from propofol to midazolam. On day 5 a single 1cm superficial clean based ulcer in the left groin was identified (Figure 2). Biopsy of the lesion (Figure 3) revealed pseudoepitheliomatous hyperplasia with underlying dermal micro abscess. Tissue stain and culture were negative for legionella or any other infectious organism. His clinical picture started to improve thereafter with antibiotic therapy. 2 weeks after his admission, his triglyceride and lipase levels normalized at 145 and 40, respectively. His respiratory status improved to where he was able to be weaned from the ventilator. Renal function, however, was not able to recover necessitating long-term dialysis.

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