INTRODUCTION: Pasteurella multocida is a rare cause of pneumonia mainly occurring in patients with underlying lung disease and contact with domestic animals. Symptoms of P. multocida range from mild cough to hemoptysis and can present acutely or as a chronic infection. Aberrant bronchial arteries have been described in chronic lung infections and are associated with massive hemopytsis. Pulmonary sequestrations can be congenital or acquired, are normally found in the left lower lobe; and typically should be sent for resection. Anomalous arteries supplying lung tissue with normally communicating bronchial airways has been termed Pryce type 1 anomaly, and pseudosequestration when associated with consolidation.
CASE PRESENTATION: An 80 year old female presented to the emergency department with a two day history of hemoptysis. Her past medical history was significant for chronic bronchitis, breast cancer, and previous pneumonia. She was a former 20 pack-year smoker and her daughter frequently visited with a small dog. Over the previous 5 months she had noted weight loss, increasing dyspnea, and fatigue. Upon presentation she was afebrile, however had a leukocytosis of 11,400 K/UL. The patient continued to cough blood and was intubated for airway protection. Computed tomography (CT) of the chest showed a left lower lobe dense consolidation distal to bronchial narrowing. Interventional radiology performed aortic angiography revealing a dilated and tortuous bronchial artery feeding the left lower lobe consolidation and an abnormal parenchymal blush. The artery was embolized and cessation of distal flow was confirmed. A subsequent bronchoscopy showed inflamed and edematous left-sided bronchi and cessation of bleeding. Given her prior cancer history, there was some concern for recurrent cancer with post obstructive pneumonia. Due to an increasing white blood cell count and febrile episodes a bronchoalveolar lavage (BAL) was performed and she was started on therapy for severe pneumonia. BAL cultures showed heavy growth of P. multocida and the patient was treated with a 10 day course of a respiratory fluorquinolone. A 6 week follow-up chest CT showed resolution of the consolidation and bronchoscopy revealed mildly stenotic left lower lobe airways without mucosal abnormality. The patient’s fatigue and dyspnea had improved at follow-up.
DISCUSSION: We present a case of an elderly female with a history of chronic bronchitis presenting with massive hemoptysis associated with P. multocida pneumonia and pseudosequestration. P. multocida is often a colonizer in individuals with an appropriate exposure history, but may present as pneumonia in the elderly or those with chronic lung disease. Severity of respiratory infection is directly related to a patient’s comorbidities, and is associated with a mortality rate as high as 30%. Cases of hemoptysis from this infection have been described previously, but typically with acute infections.
CONCLUSIONS: This case illustrates some usual presenting features for a chronic P. multocida lung infection with an unusual finding of pseudosequestration and hemoptysis. This high mortality rate, and risk for the elderly patient should make this an increasingly concerning cause of community acquired infection. Additionally, prior to sending a patient for resection of a pulmonary sequestration or mass, one should consider bronchoscopy or empiric treatment for chronic pneumonia. A clue for pseudosequestration is the arterial supply comes from a normally present but hypertrophied systemic artery rather than an anomalous artery. Disclaimer: The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Department of Defense, the Department of the Navy, or the naval services at large.
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DISCLOSURE: The following authors have nothing to disclose: Jimmy Suvatne, Melissa Butts, Joel Nations
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