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he weekend quiet of the ICU was broken by the familiar loud series of beeps and buzzes. The respiratory therapist looked at her watch. ''He's not going to make it for even 10 minutes today.'' She strode quickly into the room. A young man lay in the bed surrounded by equipment. His face gleamed with sweat; his large abdomen heaved. A monitor showed that his heart was beating rapidly. His breaths were fast and harsh-sounding as he struggled to get air through the ''trach'' -- the white plastic tube that protruded from his throat. His wife looked up at us, tired, worried.

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The respiratory therapist moved quickly to reattach the man to the ventilator, which immediately took over his breathing. We had been trying, once again, to see if the young man could be weaned from the vent -- if he could breathe without the help of the machine on which he had depended since he came to the hospital a few weeks earlier.

''I can't breathe,'' he whispered the day he arrived at the emergency room. He'd had a cold and a cough, but now he felt out of breath. ''Like I ran up the stairs,'' he gasped, ''but all the time.'' He had no fevers, no chills; just a headache and this difficulty breathing. And he was tired, really tired. He hadn't slept well for several months. But these last few days, he couldn't stay awake. ''I couldn't even drive here today,'' he admitted softly.

He was just 23 years old. He had no doctor -- he didn't think he needed one. He worked as a mechanic and lived with his wife and new son. As he told his story to the medical team, his eyes closed. The young E.R. doctor shook his shoulder. ''I'm sorry,'' he stammered. ''I just can't stay awake.''

The patient was quite obese. He was average height, maybe 5-foot-7, but he probably weighed 350 pounds. He had curly dark hair and a sweet face, round and smooth. His plaid, short-sleeved shirt was drenched with sweat.

Investigation

On examination, his heart was beating rapidly, and he breathed with quick, noisy breaths. Despite his effort, the meter on his finger showed that the oxygen in his blood was low, at 88 percent (100 percent is normal). His lungs were clear at the top two-thirds but silent at the bases: was it an infection or just his size that kept him from breathing deeply? Blood tests suggested that it was an infection, and a chest X-ray confirmed that he had pneumonia in both lungs.

A third test explained his unusual sleepiness. It showed that the patient had high levels of carbon dioxide in his blood. Normally, you breathe in oxygen and breathe out carbon dioxide. Elevated levels of carbon dioxide make you sleepy. Our patient had what is quaintly called Pickwickian syndrome, so named after a character in Charles Dickens's ''Pickwick Papers.'' Those with this syndrome, like Joe, the character in the book, and like our own patient, are obese and, because of that, can't clear their lungs of carbon dioxide. Also known as obesity hypoventilation syndrome, it was first described in the medical literature in the 1950's and is now a widely recognized complication of morbid obesity.

It was clear to us that the pneumonia was making his Pickwickian syndrome worse. His body was working hard to fight the infection. But the harder the body works, the more carbon dioxide it makes, so the sleepier the patient became. If his pneumonia didn't resolve quickly, he would need a ventilator to help him breathe. Sure enough, after two days, he was intubated.

Slowly, with the help of antibiotics and the ventilator, he came through a terrible pneumonia. His fever came down, his blood pressure came up and finally his lungs began to clear. But now it seemed his recovery was at a standstill. He should have been able to come off the ventilator. Yet he couldn't. Moreover, he continued to run a low-grade fever. Clearly, something else was going on. That morning on rounds, we considered the possibilities.

Infection was certainly the most likely cause of his fever, but his lungs were working better. Did he now have another infection? If so, where? Or could it be something else? Drugs can cause a fever as part of an allergic type of reaction, and he was on many. Tumors can as well, though we had no reason to think that this young man had a tumor.

Blood clots are always a risk in those who have extended illnesses. Although our patient had been on blood thinners throughout his hospital stay to prevent these clots, they remained a possibility. Finally there was atelectasis, a partial collapse of the lung. This is a common concern in hospitalized patients whose immobility and pain discourage them from taking the deep breaths that keep lungs working well. Still, atelectasis didn't usually cause a fever like the one our patient had.

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