A 78-year-old woman with a history of hypertension, type 2 diabetes mellitus, generalised osteoarthritis, NYHA stage II congestive heart failure and chronic atrial fibrillation. She was being treated with metformin (850 mg/8 hours), glipizide (5 mg/day), lercanidipine (10 mg/day), lisinopril-hydrochlorothiazide (20/12.5 mg/day), acenocoumarol and occasionally ibuprofen. Two days before admission due to increased bone pain, she received ibuprofen (600 mg/8 hours), and subsequently began to show general deterioration, vomiting and decreased level of consciousness.
In the emergency department she was hypotensive and poorly prefused in coma (Glasgow 6/15) and blood tests showed plasma creatinine of 1.79 mg/dl, glycaemia of 215 mg/dl and prothrombin time of 7%. Arterial blood gases had a pH of 7.03 with bicarbonate of 10 mEq/l and plasma lactic acid of 14 mmol/l. Chest X-ray revealed a left base infiltrate.

She was transferred to the intensive care unit (ICU) and underwent orotracheal intubation with mechanical ventilation and administration of vasoactive drugs and antibiotics. A lumbar puncture was indicated, the result of which was compatible with pneumococcal meningitis. Haemodialysis with a bicarbonate bath was performed, and the patient's blood tests subsequently improved, with plasma creatinine (Cr) of 1.2 mg/dl and serum bicarbonate of 22 mEq/l. However, the patient remained in coma, with EEG with low voltage waves, and died 72 hours after admission.