SESSION TITLE: Bronchology Cases
SESSION TYPE: Case Reports
PRESENTED ON: Sunday, March 23, 2014 at 09:00 AM - 10:00 AM
INTRODUCTION: Bacterial pseudomembranous tracheobronchitis is rare in the adult. There have been two cases reported from Japan showing tracheobronchitis due to Staphylococcus Aureus requiring tracheotomy and mechanical ventilation, one of them dying from complications. In immunocompromised patients, most cases reported have been secondary to aspergillus infection and have been associated with high mortality. We present an immunocompromised patient with bacterial pseudomembranous tracheobronchitis due to post-influenza S. Aureus infection.
CASE PRESENTATION: A 23 y/o man with AML s/p PBSCT, C-GVHD with pulmonary involvement on immunosupression presented with complaints of productive cough, fevers, night sweats, body aches, arthralgias, low back pain, dyspnea and costal pain. He was recently diagnosed with influenza A. Physical exam was pertinent for regular tachycardia, tachypnea, erythematous oral mucosa with white plaques, focal wheezing at left lung base, and scattered hyperpigmentation on skin. There was no respiratory distress. X-ray showed irregular basilar densities. CT scan showed patchy areas of mixed groundglass and nodular airspace disease. He was started on broad spectrum antibiotics which included cefepime, vancomycin, metronidazole, and caspofungin. Labs were pertinent for hypoxemia with PO2 at 78 on 5L NC and a WBC count of 10.3. Bronchoscopy with BAL was done showing diffuse inflammation with mucosal sloughing throughout with significant thick secretions and partial obstruction of airways consistent with pseudomembranous tracheobronchitis. Cell counts showed neutrophilic alveolitis with intra and extracellular cocci with degenerative cellular changes. Staphylococcus Aureus grew on cultures and influenza B by PCR with negative aspergillus antigen. Antibiotic treatment was tailored to S. Aureus and patient improved to discharge in 4 days.
DISCUSSION: Our patient underwent early bronchoscopy with airway clearance and identification of pathogen by BAL. With appropriate therapy he was able to be discharged avoiding mechanical ventilation and tracheotomy in contrast to reported cases.
CONCLUSIONS: Bronchoscopy with visualization of airway and lower respiratory samples is essential in the management of immunocompromised patients with respiratory symptoms particularly if disproportionate to imaging findings as it may imply airway involvement.
Reference #1: Yamazaki Y, Hirai K, Honda T. Pseudomembranous tracheobronchitis caused by methicillin-resistant Staphylococcus Aureus. Scand J Infect Dis 2002; 34:211-213
Reference #2: Namba Y, Mihara N, Tanaka M. [Fulminant tracheobronchitis caused by methicillin-resistant Staphylococcus. Nihon Kyobu Shikkan Gakkai Zasshi 1997; 35:969-973
Reference #3: Fernandez-Ruiz M, Silva JT, San-Juan R, et al. Aspergillus tracheobronchitis: report of 8 cases and review of the literature. Medicine (Baltimore) 2012; 91:261-273
DISCLOSURE: The following authors have nothing to disclose: Rafael Calderon Candelario, Karen Wood, Troy Schaffernocker
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