Cloudy Hypoxia After Foreign Travel

Author: William Tansey, Sachin Sekhsaria, Harjinder Chaggar / Editor: Stephen Sheridan / Codes: IC5, IP2, ResP2, RP5, SLO3 / Published: 27/02/2026

This independent, previously active tourist arrived from India four weeks ago. He is an ex-smoker (40 pack-year history, quit 5 years ago) with no known drug allergies. His past medical history includes well-controlled hypertension, gallstones, hypercholesterolaemia, and type 2 diabetes.

He reports a 5-day history of fever and lethargy, progressive shortness of breath, and an intermittent non-productive cough. In the last 48 hours, he developed a vesicular rash, and today he became confused and difficult to rouse.

Vital signs: Temperature 38.2°C, SpO₂ 89% on 15 L/min O₂ via non-rebreather mask, BP 124/73 mmHg.

Arterial blood gas: pH 7.339, pO₂ 7.37 kPa, pCO₂ 4.29 kPa, Na⁺ 127 mmol/L, lactate 3.3 mmol/L, HCO₃⁻ 18.2 mmol/L, base excess −8.5.

Examination:

• CVS: Normal heart sounds, no murmurs.
• Respiratory: Bilateral transmitted crackles, sparse expiratory wheeze.
• Abdomen: Soft, non-tender, no organomegaly.
• Neurology: No lateralising signs, no features of encephalitis/encephalopathy.

Bloods, cultures, and a portable chest X-ray are requested.

Initial management (following on-call microbiology advice):

• High-flow Oxygen
• IV Co-amoxiclav
• Oral Aciclovir
• Arterial monitoring: Arterial line facilitates serial ABG’s and can accommodate later invasive cardiac output monitoring.
• CPAP planned once a side room is available, with step-up care to HDU.