Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

Pulmonary Hemorrhage From Stenotrophomonal Pneumonia in Leukemics FREE TO VIEW

Aritra Sen, MD; Surya Palakuru, MD; Diwakar Balachandran, MD
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UT Health Science Center, Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):196A. doi:10.1016/j.chest.2016.08.205
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Risk factors and hospital course of leukemic patients suffering from pulmonary hemmorhage secondary to Stenotrophomonas maltophila (Sm) pnuemonia are discussed.

CASE PRESENTATION: Fifty-nine year old Caucasian gentleman with AML in remission presented with high grade fever (103.2) and pleuritic chest pain accompanied by dyspnea on exertion and dry cough. The patient’s AML was treated with CIA and Sorafinib for three cycles and he was in complete remission. On initial assessment, he was sitting comfortably in bed with 2L nasal cannula. He was clear to bilateral auscultation except mild crackles at bottom; there was no wheezing or use of accessory muscles. His chest X-ray was initially clear. A bronchoscopy was promptly done with BAL showing 560 RBC/uL and 17 WBC/ uL (93% mononuclear cells). After bronchoscopy, the patient became persistently hypoxemic and had hemoptysis. After intubation and rescucitation, repeat chest X-rays showed progressive white out of left hemithorax. Repeat bronchoscopy showed copious fresh and old blood from the left lower lobe posterior basal segment. Local epinephrine and thrombin achieved hemostasis only for a brief amount of time. Blood and BAL cultures were positive for Stenotrophomonas maltophila. The patient continued to deteriorate and later passed.

DISCUSSION: Leukemics often are immunosuppressed for days to weeks secondary to induction chemotherapy or stem cell transplantation. Literature shows leukemics with Sm infections are uniquely at risk for pulmonary hemorrhage and high mortality. A recent 2013 review of 1,085 HSCT patients showed 42 seperate Sm infections, seven of which developed pulmonary hemorrhage and died. Pulmonary hemorrhage was not seen among non-HSCT patients. Upon further review, prolonged neutropenia, high CRP and D-index were associated with hemorrhage. Previous papers found neutropenia and thrombocytopenia risk factors for hemorrhage after chemotherapy, with mortality occuring in 36-72 hours. Although unknown, alveolar damage was found in histological specimens. Blood and sputum culture did not result until the patient expired.

CONCLUSIONS: The mechanism of alveolar hemorrhage is unclear but proteases coded by StmPrl are believed to cause alveolar necrosis. With patients profoundly neutropenic and thrombocytopenic, extensive tissue damage leads to uncontrolled hemorrhage and multi-organ dysfunction. Given that these patients decompensate in a short period of time, these patients should have cultures performed prior to becoming sick. If Sm is found, earlier treatment with antibiotics would likely decrease mortality from hemorrhage.

Reference #1:Stenotrophomonas maltophila infection in hematopoietic SCT recipients: high mortality due to pulmonary hemorrhage. Tada et al Bone Marrow Transplantation 2013

Reference #2:Lethal Pulmonary Hemorrhage Caused by a Fulminant Stenotrophomonas maltophila Respiratory Infection in an Acute Myeloid Leukemia Patient. Rousseau et al. Leukemia & Lymphoma 2004

DISCLOSURE: The following authors have nothing to disclose: Aritra Sen, Surya Palakuru, Diwakar Balachandran

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