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An Odd Culprit of Primary Pleuropulmonary Infection FREE TO VIEW

Umbreen Arshad, MD; Leena Pawar, MBBS; Omair Chaudhary, MD; Ruby Appiah, MD; Dana Savici, MD
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Upstate Medical University, Syracuse, NY

Chest. 2014;146(4_MeetingAbstracts):160A. doi:10.1378/chest.1966001
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SESSION TITLE: Infectious Disease Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: With primary pleuropulmonary infections in the absence of trauma, a penetrating injury, invasive procedure or surgery, it is strikingly uncommon that the culprit be isolated as part of the clostridia species. Such infections are generally characterized by a necrotizing pneumonia often with involvement of the pleura and are associated with some iatrogenic cause. It is now being recognized that other predisposing factors may include aspiration of oropharyngeal or gastric contents as well as pulmonary embolism with infarction. The clinical course tends to be very indolent and aggressive, often resulting in fatality.

CASE PRESENTATION: A 50 year old female with a history of emphysema, PE/DVT presented with severe back pain, pleuritic chest pain and dyspnea. CT scan showed a PE with a possible PNA and loculated effusion of the right lower lobe (RLL). Heparin drip was started but subsequently she went into respiratory failure and shock requiring pressors and vent support. TPA was given and since she was penicillin allergic, started on levofloxacin and vancomycin. Further investigation found a RLL infarct with necrosis and super infection. Antibiotics were changed to meropenem ,clindamycin and vancomycin once gram stain showed gram positive rods. Cultures grew clostridium bifermentans and aspergillus niger so patient was taken to OR. She had a grossly necrotic lung and underwent right thoracotomy with debridement and washout. The patient was eventually titrated off pressors and extubated. She continued antibiotic therapy with meropenem and voriconazle and completed acute rehab.

DISCUSSION: Clostridium necrotizing pneumonias have rarely been described in the literature and even scarcer is the isolation of clostridium bifermentans as the causative agent. These gram positive rods are anaerobic organisms that form endospores and clostridium perfringens is the species which is most frequently isolated from pleuropulmonary infections. We speculate that given the lack of clear trauma, haematogenous isolation of the pathogen, invasive surgery or procedure that there maybe have been a subclinical episode of aspiration which was superimposed on the already damaged lung tissue. Based on our extensive search, this is the second case reported regarding this particular clostridia species in association with pulmonary thromboembolism. In this setting, the necrotic lung tissue from the embolus may serve as a nidus for growth of anaerobic or microaerophilic organisms.

CONCLUSIONS: Thus, when signs of pleuropulmonary infection become evident in a patient with PE, infracted lung and pre-existing chronic lung disease, the possible pathogenic role of this organism must be considered. The literature describes treating such patients with penicillin and we further extend treatment with clindamycin or meropenem in penicillin allergic.

Reference #1: C Palmacci, et al. "Necrotizing Pneumonia and Sepsis Due to Clostridium Perfringens: A Case Report." Cases Journal 2.1 (2009): 50.

DISCLOSURE: The following authors have nothing to disclose: Umbreen Arshad, Leena Pawar, Omair Chaudhary, Ruby Appiah, Dana Savici

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