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Abstract

Case Reports: A 25 y/o nonsmoker, atopic male presented with 3 days of viral-like symptoms. CT chest was negative for pulmonary embolism, but revealed scattered ground glass opacities (GGO). He developed acute respiratory failure, initially placed on BiPAP and then emergently intubated (pH 7.14, paCO2 86, paO2 83 on FiO2 1). Peak airway pressures were above 60mmHg and he required paralytics. Bronchoscopy revealed thick secretions and diffuse mucosa erythema. Studies showed 12% eosinophils (64/mm3) on BAL, acute inflammation on cytology, and cor pulmonale on echocardiogram. Chest CT revealed pneumomediastinum and GGO. All immunology, microbiology and viral studies were negative.He was liberated from ventilation after 2 days, and made a rapid recovery on IV steroids and nebulized albuterol. Spirometry, lung volumes and diffusing capacity 4 weeks after discharge were normal. Cor pulmonale was resolved on repeat echocardiogram. CT chest showed resolution of pneumomediastinum and GGO. His alexithymia score was 53 per the 20 question Toronto Alexithymia Scale (TAS-20).Near fatal asthma (NFA) is defined as sudden onset respiratory arrest, need for mechanical ventilation, paCO2 of >50mmHg or pH <7.3 in asthmatic patients1. Mortality rate in those requiring mechanical ventilation is 16.5%2. Pathologically, predominant eosinophilia, remodeling with acute and chronic inflammation and an eosinophilic BAL (average 54/mm3) is seen3.Alexithymia is a psychological trait of difficulty recognizing body sensations and describing emotions which can blunt the perception of the severity of symptoms, such as dyspnea. It is seen in 36% of known asthmatic patients with NFA and can be detected by TAS-204. However, alexithymia has not been found to be associated with newly diagnosed asthmatic patient with NFA.This unique initial presentation of NFA with no clear history of asthma is not described in literature. Our patient’s atopic history, acute respiratory failure with increased airway resistance, barotraumas, increased BAL eosinophils and response to corticosteroid therapy highly suggests asthma presenting with NFA. Alexithymia may have led to under recognition of his symptoms.