Managing Critical Illness Myopathy after ARDS and Legionnaires: A Case Report

Case Diagnosis: Critical Illness Myopathy (CIM) in the setting of severe acute respiratory disease (ARDS) with Legionnaires

Case Description or Program Description: A 56-year-old female presenting with dyspnea, fever, and fatigue was diagnosed with Legionella, severe sepsis, ARDS, and multi-system organ failure, requiring intubation and percutaneous endoscopic gastronomy tube placement. She was admitted to rehab on 1 liter nasal cannula with lower extremity weakness (⅗ right, ⅘ left).
Rehab was complicated by difficulty swallowing, congestion, productive cough, persistent hypoxia, and thick yellow phlegm. Pulmonology noted scattered ground-glass opacities and positive fungal cultures; bronchoscopy was unremarkable but revealed Influenza, prompting Tamiflu treatment. Nephrology managed hypercalcemia, elevated creatinine, acute tubular necrosis, and chronic kidney disease IIIb, adjusting medications and initiating Sevelamer. Hematology/Oncology treated anemia with Aranesp and recommended bone biopsy outpatient after faint M-spike with IgG kappa monoclonal band.

Setting: Inpatient rehabilitation unit

Assessment/Results: During therapy, oxygen saturation ranged from 85–91%. With incentive spirometry and diaphragmatic breathing, she improved and transitioned to room air (90% saturation). Initially ambulating 30 feet with an unsteady gait (partial-moderate assist), she progressed to 100 feet with a leaning gait at modified independent status

Discussion (relevance): CIM can be diagnosed based on lower extremity weakness and a history of multi-organ failure. Mechanically ventilated intensive care unit (ICU) patients often develop diaphragmatic weakness due to muscle disuse, increasing aspiration risk, difficulty weaning, and mortality. This patient faced respiratory complications, including oxygenation issues and pneumonia, likely from inadequate rehabilitation post-ICU. However, with diaphragmatic breathing and incentive spirometry, their oxygenation and therapy participation improved. This case underscores the importance of early CIM recognition and disease management to ensure proper pulmonary rehabilitation and prevent worsening outcomes

Conclusions: Understanding the nuances of management for CIM post mechanical ventilation is vital to patients’ recovery. Proactive consultation for the necessary specialties and administration of pulmonary rehab can be vital to ensure prevention of worsening complications