UCLA-Olive View Medical Center, Venice, CA
Copyright 2016, American College of Chest Physicians. All Rights Reserved.
SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary gangrene is a rare complication of community-acquired pneumonia (CAP). In adults it is classically caused by Klebsiella pneumoniae (1, 3). We describe a case caused by the less common etiologic agent Streptococcus pneumoniae.
CASE PRESENTATION: A 37 year old male presented with productive cough, fever, and dyspnea and initial vitals of T 37.2, HR 128, RR 24, BP 99/78, SaO2 91% on room air. He was severely tachypneic despite NiPPV and was intubated. Chest x-ray (CXR) was notable for near-complete right hemithorax opacification and patchy left-sided opacities (image 1). A computed tomography (CT) showed dense confluent consolidation of the right lung and multifocal consolidation on the left. He was admitted to the intensive care unit for septic shock and hypoxic respiratory failure due to multifocal pneumonia and was started on broad-spectrum antimicrobials. Blood cultures grew S. pneumoniae. CT revealed new cavitary lesions in the right lung (image 2). Despite a thorough infectious work-up and antibiotics, he had persistent fevers thought to be secondary to pulmonary gangrene. A third CT showed near complete opacification of the right lung with increased cavitation. Bronchoscopy was notable for aspiration of necrotic lung parenchyma. He was discharged home after 37 days.
DISCUSSION: It is not known why some patients with S. pneumoniae CAP develop pulmonary gangrene. Risk factors that lead to a necrotizing or gangrenous infection in one patient, while the same organism causes a non-necrotizing pneumonia in another, have yet to be elucidated. Necrotizing pneumonia is rarely evident on initial imaging. While this patient had multifocal pneumonia at presentation, it was not until subsequent CTs that cavitations and necrosis were seen. Consistent with other reports, our patient presented severely ill and rapidly deteriorated (3). Serial CT imaging revealed the rapid progression of his infection. There are no guidelines for the management of pulmonary gangrene. Most case reports in which the patient survives involve surgical resection (2). In our case, necrotic tissue was removed via bronchoscopy and the patient recovered without surgical intervention.
CONCLUSIONS: Further research is needed to determine which patients are at greater risk for necrotizing pneumonia or pulmonary gangrene. If clinical suspicion is high, repeat imaging should be obtained. Surgical management may be required, however less invasive evacuation of necrotic material may be sufficient.
Reference #1: Penner, C., Maycher, B., & Long, R. (1994). Pulmonary Gangrene. Chest, 105(2), 567-573.
Reference #2: Chen, C., Huang, W., Chen, T., Hung, T., Liu, H., & Chen, C. (2009). Massive Necrotizing Pneumonia With Pulmonary Gangrene. The Annals of Thoracic Surgery, 87(1), 310-311.
Reference #3: Chatha, N., Fortin, D., & Bosma, K. J. (2014). Management of Necrotizing Pneumonia and Pulmonary Gangrene: A Case Series and Review of the Literature. Canadian Respiratory Journal, 21(4), 239-245.
DISCLOSURE: The following authors have nothing to disclose: Marin McCutcheon, Nader Kamangar
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