Catastrophic Hypoxic-Ischemic Brain Injury Following Influenza A Illness in a Young Woman: A Case Report.

Seasonal viral respiratory infections such as influenza are typically self-limited but can, in rare instances, precipitate severe systemic and neurologic complications. We report the case of a previously healthy 27-year-old woman who developed rapid neurologic collapse one week after flu symptoms and testing positive for influenza A. She presented with altered mental status and experienced a witnessed seizure requiring emergent intubation, followed by refractory shock necessitating multiple vasopressors. Neuroimaging demonstrated diffuse cerebral edema with cerebellar tonsillar herniation and hyperdensity of the basal cisterns, with subsequent computerized tomography (CT) angiography revealing absence of cerebral perfusion. Neurologic examination remained consistent with profound brain injury, including a Glasgow Coma Scale score of 3, consisting of no eye opening, no motor response, and no verbal response. Her clinical course was consistent with hypoxic-ischemic brain injury secondary to systemic hypoperfusion and hypoxemia in the setting of viral illness and septic shock. The patient ultimately died following withdrawal of life-sustaining therapy. This case highlights the potential for viral prodromes to trigger catastrophic neurologic injury through systemic inflammatory, hypoxic, and hemodynamic mechanisms, even in young patients without preexisting disease. Early recognition of malignant cerebral edema, pseudo-subarachnoid hemorrhage, and absent cerebral perfusion on advanced imaging is critical for prognostication and timely goals-of-care discussions. Additionally, the patient had positive cocaine test results, raising the possibility that sympathomimetic toxicity or cocaine-associated vasculopathy may have contributed to the severity of cerebral edema. Finally, this case underscores the importance of influenza vaccination as a potentially preventable factor in rare but devastating neurologic complications of viral illness.