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Diffuse Lung Disease |

Hypoxic Respiratory Failure Secondary to Acute Lupus Pneumonitis

Meredith Barnes*, BA; Thura Abd, MD
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Emory University School of Medicine, Atlanta, GA


Chest. 2012;142(4_MeetingAbstracts):468A. doi:10.1378/chest.1382069
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Abstract

SESSION TYPE: ILD Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute lupus pneumonitis is a rare yet important complication of Systemic Lupus Erythematosus (SLE) that is often unrecognized and associated with delayed therapy.

CASE PRESENTATION: An 18-year-old female with a history of SLE on maintenance prednisone presented to the Emergency Department with cough and fever for two weeks. Her pulse was 161, temperature 40.7°C, blood pressure 86/58, respiratory rate 18, and SpO2 94% on room air. Chest X-ray (CXR) showed bronchocentric interstitial airspace opacities, and CT showed extensive cystic change, septal thickening, and ground-glass opacities. CXR 4 months prior to admission was normal. Broad-spectrum antibiotics, trimethoprim/sulfamethoxazole (TMP/SMX), and steroids were empirically started for community-acquired pneumonia and Pneumocystis Jiroveci (PJP) treatment. Bronchoaleveolar lavage (BAL) was negative for PJP, influenza, respiratory viruses, acid-fast bacilli (AFB), and legionella, so TMP/SMX was discontinued. She improved and was discharged on levofloxacin, returning to her maintenance prednisone dose. Two days later, she presented with recurrent symptoms. CXR showed slight worsening of airspace opacities. Repeat bronchoscopy with biopsy was negative for AFB, fungal culture, and bacterial culture. Cytological examination of BAL fluid showed evidence of acute inflammation without microorganisms or viral cytopathic effect. Biopsy revealed mucoid secretions with inflamed mucosa and scar tissue with interstitial chronic inflammation without granuloma or exudates. She was started on antibiotics for healthcare associated pneumonia and discharged on TMP/SMX and levofloxacin. A week later, she returned with similar symptoms. Admission vitals showed temperature of 39.4°C, BP 102/67, pulse 156, respiratory rate 20, and O2 saturation 97% on room air. On exam, she had diffuse inspiratory crackles best heard at the lung bases. Blood work showed a normal white count and decreased C3 and C4 levels. Broad-spectrum antibiotics were empirically started for healthcare associated pneumonia. Given her repeated negative work up for infectious etiologies and poor response to antibiotics during prior admissions, acute lupus pneumonitis was suspected. Antibiotics were stopped on hospital day 2, and patient was started on high dose steroids, which resolved her symptoms. On outpatient follow up, patient was asymptomatic without respiratory complaints on steroid taper regimen

DISCUSSION: Acute lupus pneumonitis should be considered in SLE patients presenting with respiratory complaints when infectious work-ups fail to reveal causative microorganisms.

CONCLUSIONS: Failure to recognize this unusual pulmonary manifestation of SLE can lead to significant delay in initiating appropriate treatment.

1) Cheema G, Quismorio F. "Interstitial lung disease in systemic lupus erythematosus." Current opinion in pulmonary medicine 6.5 (2000):424-429.

DISCLOSURE: The following authors have nothing to disclose: Meredith Barnes, Thura Abd

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Emory University School of Medicine, Atlanta, GA

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