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: DAH is an acute life threatening condition often associated with systemic disorders such as vasculitis, infections, toxins or patients on immunosuppression. Mycoplasma pneumonia is a common cause of community acquired pneumonia and rarely causes fulminant disease and respiratory failure. We report here a case of mycoplasma pneumonia in an immuno-competent female causing DAH and ARDS requiring mechanical ventilation and VV-ECMO.
CASE PRESENTATION: Our patient is a 20 year old female with no significant past medical history presenting with cough, shortness of breath and subjective fevers for 4 days. She was seen twice in the emergency department and was treated with levofloxacin and prednisone for presumed community acquired pneumonia. She was subsequently admitted for worsening shortness of breath and hypoxia with O2 saturation of 89% on room air. Notable physical exam findings included scattered wheezing on auscultation. Labs revealed a WBC count of 15,300 with 91% neutrophils, 5% lymphocytes. Hemoglobin was 8.6 g/dl with 194,000 platelets. Metabolic panel was normal with a normal Brain Natriuretic Peptide. Arterial blood gas on 60% FiO2 via nasal cannula revealed a pH of 7.43, pCO2 35, pO2 of 69 and HCO3 of 22. Chest x-ray revealed left lower lobe, right lung base and right perihilar infiltrates. She was started on emperic antibiotics, steroids and nebulizer treatments. Sputum cultures as well as influenza A & B screening was negative. Further hypoxia developed requiring mechanical ventilation on day 2 of hospital course. CTA of the chest was done which showed extensive peripheral infiltrates in the mid and lower lung zones and within the lung apices with no evidence of pulmonary embolism. Bronchoscopy demonstrated DAH and she was started on high dose steroids. Rheumatological workup done was negative. Infectious etiology was remarkable only for mycoplasma IgM which was elevated at 777 U/mL. The patient clinical status worsened, requiring transfer to our institution on day 11 of admission for nitric oxide and possible VV-ECMO. Repeat bronchoscopy demonstrated DAH. Her rheumatological work-up was repeated and was negative. After nine days on nitric oxide, VV-ECMO and high dose steroids; the patient was able to be successfully weaned off mechanical ventilation. She recovered well and was discharged to rehab facility 51 days after originally being admitted.
DISCUSSION: In immunocompetent people the most frequent infectious causes of DAH are influenza A, dengue, malaria and staphylococcus aureus infections. ARDS secondary to mycoplasma pneumonia is very rare and it leading to DAH is unheard of. We present the first reported case of mycoplasma induced DAH requiring VV-ECMO in an immunocompetent patient.
CONCLUSIONS: Mycoplasma pneumonia should be one of the differentials for diffuse alveolar hemorrhage.
Reference #1: Von Ranke FM, Lung. 2013 Feb;191(1):9-18. Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients.
DISCLOSURE: The following authors have nothing to disclose: Killol Patel, Nadeem Ali, Habib Nazir, Rashid Mamoona, Muneera Naeem, Christina Migliore
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