SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Organizing pneumonia (OP) is a reported complication of patients with H1N1 infection, typically after the interval development of acute respiratory distress syndrome (ARDS). Our patient, with recent history of H1N1 infection, was diagnosed as having OP by surgical lung biopsy (SLB) without the presence of pathologic features suggestive of ARDS.
CASE PRESENTATION: A 49 year-old female with history of respiratory failure secondary to presumed ARDS in the setting of active H1N1 infection had a prolonged intubation, difficulty weaning from mechanical ventilation, and subsequent tracheostomy placement, in January of 2014. She had been treated with oseltamivir and a rapidly tapering dose of empiric steroids for peripheral infiltrates seen on CT scan of the chest. Her respiratory status improved thereafter and tracheostomy was subsequently decannulated. The patient was no longer hypoxic on room air and chest radiographs had almost completely normalized. A week following this, she started to become dyspneic with exertion. She presented to our Intensive Care Unit in March 2014 with rapidly evolving hypoxic respiratory failure with rising oxygen needs over the course of a week. Chest radiographs demonstrated evolving bilateral airspace disease and high resolution CT scan of the chest showed ground-glass opacities in all five lobes with associated traction bronchiectasis and fibrotic changes at the bases. Initial investigations for infectious etiologies, including H1N1 PCR and bacterial sputum culture were negative. Cardiogenic pulmonary edema was excluded with normal echocardiography, marginally elevated NT-proBNP and after aggressive diuresis did not improve oxygen requirements. Given the patient had no risk factors to suggest development of ARDS she underwent SLB. Specimens from the right upper, middle, and lower lobes showed OP without evidence of hyaline membranes or diffuse alveolar damage, typical of ARDS. The patient was placed on methylprednisolone with subsequent extubation and rapid improvement in both her respiratory symptoms and radiographic abnormalities.
DISCUSSION: During both hospitalizations, the patient’s clinical presentation and chest radiographs were suggestive of ARDS. However, given that SLB was diagnostic of OP without any pathologic features of ARDS, we believe that OP was the etiology of our patient’s respiratory failure during both hospitalizations.
CONCLUSIONS: We suggest that it is imperative to consider OP in the differential diagnosis of patients with H1N1 infection and hypoxic respiratory failure with bilateral airspace disease.
Reference #1: Marchiori et al. Influenza A (H1N1) virus-associated pneumonia: High-resolution computed tomography-pathologic correlation. EJOR 80 (2011):500-504
Reference #2: Cornejo et al. Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza. BMJ Case Reports 2010; 22 July
Reference #3: Kumar et al. H1N1-infected Patients in ICU and Their Clinical Outcome. N Am J Med Sci. (2012) Sep; 4(9):394-8
DISCLOSURE: The following authors have nothing to disclose: Faith Eliason, Christopher Harden, Indrani Mukherjee
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