Severe Hypoxemia and Cerebral Microbleeds: A Case Report

IntroductIonAltered sensorium, or encephalopathy, is a frequent occurrence in patients admitted to the intensive care unit (ICU).Cerebral microbleeds, which can result from critical illness and severe hypoxia, may present with symptoms of altered sensorium.Delirium, characterized by a fluctuating mental state and cognitive dysfunction, is commonly diagnosed in ICU patients experiencing such symptoms.This case report focuses on an instance of cerebral microbleeds that manifested as drowsiness and altered sensorium. case descrIptIonA 40-year-old female patient was admitted to a tertiary care health facility with complaints of fever, myalgia, generalized weakness, and shortness of breath.She was evaluated at an outside hospital for community-acquired pneumonia.High-resolution computed tomography (HRCT) chest showed bilateral consolidation and ground-glass opacities.Because of desaturation, respiratory distress, and increased work of breathing, mechanical ventilation was instituted after endotracheal intubation.She received a furosemide infusion at 5 mg/hour in view of raised N-terminal pro-B-type natriuretic peptide (NT-pro-BNP >25000) and volume overload.She was in septic shock, for which noradrenaline infusion (0.25 g/kg/minute) was started after adequate fluid resuscitation.As the hypoxia persisted despite 100% oxygen and high positive end-expiratory pressure (PEEP), prone ventilation was adopted.She responded to one cycle of prone ventilation; hence, she continued on supine ventilation and was later extubated successfully to high-flow nasal oxygen (HFNO) on the 8th day of admission.From the 4th to the 8th day, she was drowsy with altered sensorium.Initially, drowsiness was attributed to septic encephalopathy or hypoactive delirium.Magnetic resonance imaging (MRI) of the brain was done, and a susceptibility-weighted image (SWI) showed multiple bilateral, near-symmetrical, extensive microbleeds involving supratentorial and infratentorial white matter, including the brainstem (Fig. 1), consistent with critical