A CASE OF POST-OBSTRUCTIVE NECROTIZING PNEUMONIA IN THE SETTING OF METASTATIC NON-SMALL CELL LUNG CANCER

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Necrotizing pneumonia (NP) is a rare condition that is characterized by pulmonary liquefaction and necrosis. Associated symptoms are fever, chills, shortness of breath and cough. Advanced sequelae include pulmonary gangrene, empyema, abscess and hemoptysis. Prognosis is poor with an overall mortality rate of 56% [1]. Here, we present an unusual case of metastatic pulmonary adenocarcinoma complicated by NP leading to the patient's demise. CASE PRESENTATION: A 70 year old male smoker with no known PMH presented with productive cough, unintentional weight loss and hemoptysis. CT chest showed narrowing of the left main bronchus and left main pulmonary artery due to a possible hilar mass (Figure 1,2). There was also an extensive left-sided consolidation with pleural effusion. The patient's significant leukocytosis was poorly responsive to antibiotic therapy. No infectious etiology could be identified on extensive testing. The patient developed acute respiratory distress requiring mechanical ventilation. Bronchoscopy showed severe bleeding from an unidentifiable source in the left lung. BAL showed possible lung carcinoma with post-obstructive PNA. CT abdomen showed right adrenal metastasis. IR-guided bronchial artery embolism was attempted twice to control bleeding; however, no source of bleeding could be identified. The chest tube drained a considerable amount of serosanguinous fluid. The patient underwent segmentectomy after worsening bleeding through the ETT and was found to have extensive metastatic disease in the chest. Lobectomy could not be performed due to the inability to access hilum and was deemed unsafe. Biopsy showed poorly differentiated adenocarcinoma with venous invasion and thrombosis and NP with scattered bacterial colonies. The patient received compassionate care given a high likelihood of imminent death. DISCUSSION: The purpose of this case report was to describe a rare case of post-obstructive NP secondary to poorly differentiated metastatic lung adenocarcinoma. Current management of NP involves the surgical removal of the necrotic tissue along with a long course of broad-spectrum antibiotics to treat the underlying polymicrobial infection [2,3]. Our patient's prognosis was very poor because of the extent of his NP and malignancy. An early approach to endobronchial stenting would have stabilized the airway which was being severely compromised by the tumor, whereas a pneumonectomy would have made it easier to control the patient's fatal hemorrhage. This is why we believe that an early and aggressive intervention would have improved the patient's outcome. CONCLUSIONS: NP in the setting of advanced pulmonary adenocarcinoma is a rare phenomenon that is poorly described in current literature. If a patient with advanced lung cancer develops NP, an early surgical intervention with palliative stenting should be considered to minimize complications. REFERENCE #1: Gillet Y, Vanhems P, Lina G, Bes M, Vandenesch F, Floret D, Etienne J. Factors predicting mortality in necrotizing community-acquired pneumonia caused by Staphylococcus aureus containing Panton-Valentine leukocidin. Clin Infect Dis. 2007 Aug 1;45(3):315-21. doi: 10.1086/519263. Epub 2007 Jun 15. PMID: 17599308. REFERENCE #2: Cengiz AB, Kanra G, Caĝlar M, Kara A, Güçer S, Ince T. Fatal necrotizing pneumonia caused by group A streptococcus. J Paediatr Child Health. 2004 Jan-Feb;40(1-2):69-71. doi: 10.1111/j.1440-1754.2004.00296.x. PMID: 14718011. REFERENCE #3: Kohno S, Koga H, Oka M, et al: The pattern of respiratory infection in patients with lung cancer. Tohoku J Exp Med 173:405-411, 1994. DISCLOSURES: No relevant relationships by Frantzcess Compas, source=Web Response No relevant relationships by Zarwa Idrees, source=Web Response No relevant relationships by Vikram Sumbly, source=Web Response No relevant relationships by Theo Trandafirescu, source=Web Response