Background: Diseases in elderly populations are commonly multifactorial due to multiple comorbidities and sedentary lifestyles. Proteus mirabilis is a highly motile opportunistic gram-negative facultative anaerobe in the intestinal tract. It primarily affects the urinary tract, but is also a rare cause of pneumonia seen in older patients with chronic lung disease and, occasionally, pericardial effusion. We present a case of an elderly male with hypoxia found to have pericardial effusion, lung atelectasis with proteus pneumonia, and recurrent sigmoid volvulus leading to multiple emergency department (ED) visits.

Case Presentation: A 68-year-old male with a history of smoking, chronic obstructive pulmonary disease (COPD), asthma, venous stasis, aspiration pneumonia, respiratory failure and recurrent sigmoid volvulus was brought to the ED from his assisted living facility with SpO2 of 80%, pH of 7.09, and pCO2 of 132.8 mmHg. Patient received supplemental oxygen and nebulizer treatment and further workup was done. Complete blood count showed red and white blood cells low at 3.97 and 3.63, respectively. CT with contrast of chest and abdomen showed left mainstem bronchus mucus plug with atelectasis and recurrent sigmoid volvulus. An urgent decompressive colonoscopy resolved his volvulus. Patient had severe respiratory acidosis post-op that required intubation given a failed bilevel positive airway trial.

The patient had a cardiac arrest the following day and was resuscitated and emergent bedside pericardiocentesis for pericardial effusions causing cardiac tamponade (evident on emergent echocardiogram). The pericardial drain remained in place for 7 days due to continued high volume drainage (>80mL/day). Additionally, a bronchoscopy successfully removed the left bronchus mucus plug and a bronchoalveolar lavage in the left lower base showed proteus pneumonia. Cefepime was initially administered and then de-escalated to ceftriaxone 3 days later. Patient was discharged to a hospice facility to continue care.

Discussion: Multiorgan involvement can lead to poor prognosis given complexities of each organ system and concern of side effects from management of other systems. The symptoms of pericardial effusion and atelectasis were masked by the most obvious sigmoid volvulus on imaging. The multifactorial etiologies of hypoxia should be considered and appropriate workup should be done in a timely fashion.

This case illustrates the importance of comprehensive workup in older populations with multiorgan diseases. Those populations with limited mobility are at significant risk of several multifactorial comorbidities that can lead to life-threatening emergencies without prompt and appropriate interventions.