An 89-year-old woman was brought to the emergency department, responding only to pain (GCS 6), with a rectal temperature of 28.5°C, hypotension (68/40), bradycardia (35/min) and bradypnoea. The remainder of the examination was unremarkable.
She was living at home with her son and a caretaker, confined to bed/wheelchair with a history of Alzheimer’s dementia, falls, hypothyroidism (on replacement), hypertension and chronic atrial fibrillation (AF) (on amlodipine 5 mg four times a day, propranolol 10 mg three times a day). Other regular medications included quetiapine (Seroquel) 125 mg four times a day and brotizolam 0.25 mg.
Laboratory tests showed no evidence of infection or metabolic disorder except acidosis (pH 7.27). Thyoid stimulating hormone (TSH) and cortisol levels were normal. Chest X-ray, head CT and urinalysis were unremarkable; ECG showed slow AF. Cultures were negative.
The patient was rewarmed externally and by warmed fluid infusions and was given low-dose dopamine, empiric ceftriaxone and methylprednisolone. She regained consciousness within 24 hours...
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