Critical Care: Student/Resident Case Report Poster - Critical Care V |

She Looks Good on Paper: A Misleading Case of Pseudomembranous Tracheobronchitis FREE TO VIEW

Wint Aye, MBBCh; Adriane Budavari, MD
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Mayo Clinic Arizona, Phoenix, AZ

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

Chest. 2016;150(4_S):455A. doi:10.1016/j.chest.2016.08.468
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care V

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: We present a case of pseudomembranous tracheobronchitis due to MRSA in a previously healthy individual.

CASE PRESENTATION: A forty-seven year old female current smoker with a history of asthma presented with five days of progressive fatigue, shortness of breath, cough, sore throat, and loss of voice and was found to be tachycardic, tachypneic, diaphoretic on arrival to the hospital. Investigations demonstrated Influenza B with multifocal opacities consistent with infection on chest CT and mild respiratory acidosis on arterial blood gas with no other abnormalities. She experienced worsening shortness of breath and tachypnea with normal oxygen saturations despite treatment with oseltamivir, levofloxacin, benzonatate capsules, nebulizers, supplemental oxygen, lorazepam, morphine, racemic epinephrine, and methylprednisolone. Otolaryngology (ENT) performed a beside laryngoscopy which revealed 80% subglottic obstruction due to copious secretions and sloughing of tissue. Following this procedure, the patient precipitously desaturated to the 70s and an emergent tracheostomy was performed along with flexible bronchoscopy showing findings consistent with Pseudomembranous tracheobronchitis (PMTB). Bronchoalveolar lavage was positive for methicillin resistant Staphylococcus aureus (MRSA) as well as Influenza B with subsequent blood cultures also growing MRSA. For the remainder of her hospitalization, antibiotics were deescalated to intravenous (IV) vancomycin, oral vancomycin for Clostridium difficile infection (CDI), and five days of oseltamivir. She was weaned off mechanical ventilation. Repeat bronchoscopies showed slight improvement in the severity of PMTB. She was discharged to complete her courses of IV and oral vancomycin for MRSA bacteremia and CDI, respectively, with follow up with ENT and Pulmonology.

DISCUSSION: Pseudomembranous tracheobronchitis is a rare complication of respiratory infection resulting in progressive respiratory failure due to airway obstruction caused by the presence of pseudomembranes. This most often presents in immunocompromised individuals such as those with hematological diseases, acquired immunodeficiency syndrome (AIDS), or post-transplant. The most frequent infectious agents are Aspergillus, Bacillus cereus, and Staphylococcus aureus. The presentation can be dramatic with fever, cough and progressive and impending respiratory failure due to airway compromise. Management involves securing a stable airway, administering supportive therapy, and treating the underlying infection.

CONCLUSIONS: Quick and appropriate multidisciplinary efforts prevented what would have likely been a catastrophic fatality in a patient with no noted abnormalities including hypoxia in this rare care of PMTB due to Influenza and MRSA.

Reference #1: Yamazaki, Yoshitaka, Kazuya Hirai, and Takayuki Honda. “Pseudomembranous Tracheobronchitis Caused By Methicillin-Resistant Staphylococcus Aureus”. Scandinavian Journal of Infectious Diseases 34.3 (2002): 211-213. Web.

DISCLOSURE: The following authors have nothing to disclose: Wint Aye, Adriane Budavari

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