A 74-year-old male was referred to the Shaoxing Second Hospital at January, 2022 complaining of fever and fatigue for 2 days. The patient was diagnosed with MND with flail arm syndrome (FAS) and severity grade stage II 1 year ago. Lung function tests were normal at that time. The patient was prescribed riluzole tablets 1 bid. so he resided in his hometown for convalescence, surrounded by lush trees and many birds living here. Since one month ago, the muscle strength of both upper limbs has further decreased and the patient was unable to raise his upper limbs above the shoulder. The family concurrently observed a reduction in the patient’s vocal intensity during speaking and coughing. No additional treatment has been administered. Physical examination showed that body temperature was 38.5 °C, pulse rate 131 beats/min, respiratory rate 22 beats/min, blood pressure 153/83 mmHg, breath sounds were coarse and lower in lung. The left thenar muscle, hypothenar muscle, and first interosseous muscle of both hands showed significant atrophy. Laboratory examination showed the white blood cell count was 12.7 × 109/L, with an elevated neutrophil ratio of 93%. The concentration of C-reactive protein (CRP) was 243.4 mg/L. The concentrations of procalcitonin (PCT, normal < 0.05 ng/ml) and interleukin-6 (IL-6, normal < 5.4 pg/ml) were 11.5 ng/ml and 634.6 pg/ml. Arterial blood gas analysis showed a pH of 7.12, PaO2 of 76 mmHg, PaCO2 of 101.3 mmHg. Chest computed tomography (CT) showed pneumonia in the inferior lobe of the left lung (Fig. 1). Bedside fiberoptic bronchoscopy showed a large amount of yellow purulent sputum in the left main bronchus. Blood and sputum cultures, as well as other routine tests for pathogenic microorganisms, yielded negative results. The mNGS of sputum obtained through bedside fiberoptic bronchoscopy showed C. psittaci and elizabethkingia anophelis (Fig. 2). The patient was diagnosed as C. psittaci pneumonia complicated with MND.
Results of fiberoptic bronchoscopy and chest CT. Fiberoptic bronchoscopy showed that trachea cannula and massive yellow purulent sputum in the left main bronchus on day 7. Reexamination on days 11, 13, and 14 showed a gradual decrease of sputum. The follow-up chest CT on the 6th day revealed an increased extent of pneumonia. After a 10-day course of doxycycline treatment and multiple bedside fiberoptic bronchoscopies with sputum aspiration, significant improvement in pneumonia was observed on the 16th, 22nd, and 48th days
The result of mNGS of sputum suggested Chlamydia psittaci infection. X-axis represents nucleotide position along Chlamydia psittaci genome;Y-axis represents sequencing depth
The patient was administrated endotracheal intubation for mechanical ventilation. Imipenem and cilastatin sodium were administered for infection control initially, bromhexine hydrochloride was administered to decrease sputum production. Then doxycycline was administered after the diagnosis of C. psittaci pneumonia and bedside fiberoptic bronchoscopy was performed to assist with sputum excretion. After multiple suctioning, fiberoptic bronchoscopy revealed reduced sputum production (Fig. 1). The patient was successfully extubated on day 17 after admission. On day 24, he was discharged with slight dyspnea and limited exercise tolerance. One month later after discharge, the patient reported normal respiratory function, and chest CT showed significant absorption.
