A 35-year-old male patient was admitted to our medical intensive care unit (ICU) because of multiple organ failure. 
The patient was born in Somalia and migrated to Austria six years ago. In his past history there were tuberculosis detectable about 15 years ago, which was treated successfully, and unspecific heart problems. Because of insomnia and depression, a tricyclic antidepressant (amitriptyline) and diazepam were prescribed. In addition, every day the patient chewed khat leaves. According to his next of kin, khat intake increased considerably during the past few days before hospital admission. In this context, they reported that the patient was sleeping nearly until noon. However, on the day of hospital admission it was difficult to rouse the patient even in the early afternoon. Hence, an emergency physician was called to the patient, who found him neurologically disturbed with the risk of aspiration. Thus, the patient was sedated, intubated, and transferred to the emergency department (ED) of our hospital thereafter. A CT scan of the brain was performed to exclude any underlying structural cause within the brain for the present unconsciousness. At the ED an electrocardiogram showed arterial fibrillation with a heart rate of 143 bpm. Conversion into sinus tachycardia was achieved spontaneously within six hours subsequently. Hemodynamics was stable during that time period. However, gas exchange was considerably compromised. After the performance of bronchoscopy, which showed no foreign bodies or massive secretions but reddened mucosa indicating aspiration of gastric acid, the patients was transferred to our medical ICU. Further clinical and laboratory data at ED admission as well as at ICU admission are presented in Table 1.
At ICU admission SOFA score was found to be 8, and SAPS II score was 46. Hemodynamic condition was stable without catecholamine support. Moreover, during ICU stay the patient developed arterial hypertension, which was treated accordingly. The patient remained intubated and under analgosedation (combined propofol and remifentanil administration) administered continuously. Pulmonary function remained significantly compromised due to present aspiration pneumonia, which proceeded into ARDS over the next few days. Therefore, transient prone positioning of the patient was performed. However, gas exchange improved under antibiotic therapy that the patient could be extubated after two weeks of mechanical ventilation. 
After the cessation of the mechanical ventilation the patient showed massive agitation indicating present delirium, which could be improved by the administration of clonidine as well as lorazepam and trazodone. Finally, the patient was discharged from the ICU after 22 days and discharged from the hospital in good condition another 14 days thereafter.