1267

Abstract

Introduction: The patient is a 78 y.o. female who presented to the hospital with complains of weakness, shortness of breath and cough. The cough was dry initially and then became productive along with malaise. She had minimal shortness of breath to begin with which increased to severe shortness of breath on presentation.She denied any chest pain, hemoptysis, fever, abdominal pain, nausea,diarrhea, vomiting. She denies any diplopia, diarrhea, constipation, headache. She had no recent sick contact. she has a pet cat which was healthy.Her immunisation was uptodate. Her past medical history was significant with atrial fibrillation,COPD,DVT off anticoagulation for one month,history of Ca breast s/p mastectomy and chemotherapy and she had been off chemotherapy for 2 years. She was recently diagnosed with a lesion of the brain with an inconclusive biopsy and was started on dexamethasone in a recent hospitalization due to partial seizures and vasogenic edema on MRI of the brain. On examination the patient was awake alert oriented in severe respiratory distress. she has a pulse of 120/min irregular, blood pressure of 126/65, respiratory rate of 25/minute and saturation of 91% on nonrebreather mask. she was febrile .The physical examination was negative except for crackles in the right infraclavicular region and rhonchi bilaterally.The patient was intubated and treated with esmolol and cardizem which controlled her heart rate. The lab studies revealed pancytopenia with white count of 0.9 K/uL with absolute neutrophil count of 0.6k/ul and platelet count of 14 K/uL. The other laboratory values including hepatic, renal function were within normal range. The chest xray revealed right upper lobe dense consolidation. The CT chest without contrast revealed dense consolidative infiltrate in the right upper lobe with air bronchograms along with infiltrates in the left upper lobe.The patient was started on treatment for health care associated pneumonia with piperacillin tazobactam, levofloxacin and vancomycin. The test results for L. pneumophila urinary antigen were sent and were negative.In view of neutropenia the patient underwent a bronchoscopy which was essentially normal except for purulent lavage from the the right upper lobe. Hematology was consulted for the panctyopenia who suggested a possibility of metastasis to the marrow vs a new hematological malignancy in light of a recent discovery of brain lesion. The patients white count and the platelet continued to decrease. The patient was given filgrastim with a brisk rise of the white count. In view of response of the white count to filgrastim metastasis to the bonemarrow was lowered in differential. The patient received mechanical ventilation which resulted in progressive improvement of blood gas exchange and the patient was extubated on day 3.The patient remained afebrile and hemodynamically stable with no need for pressors. In view of persistent thrombocytopenia a plan for bone marrow aspiration and biopsy was made. The bronchoalveolar lavage was positive for LEGIONELLA PNEUMOPHILA DFA stain and negative for bacterial, viral or fungus. The patients antibiotics were descalated to only levofloxacin. The platelet count and the white returned to normal on day 12 of treatment and remained normal therafter through the course of admission. Her hospital stay was complicated with new deep venous thrombosis for which she had an inferior venecava filter placed. The patient was subsequently transferred from the intensive care unit with a diagnosis of pancytopenia secondary to severe legionella pneumonia. In conclusion - we present a case of severe legionella pneumonia which presented with severe pancytopenia. she was initially treated as pneumonia secondary to pancytopenia with a differential of new hematological malignancy vs metastatic breast cancer to the bone marrow. we suggest legionella pneumonia to be kept as a differential in patients with pneumonia and pancytopenia.