Alveolar Microcirculation Injury in an Immunocompromised Patient With Influenza

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Diffuse Lung Disease SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a life threatening condition of alveolar microcirculation injury from vasculitic disorders, connective tissue diseases and some infections, like Influenza. We present a case of DAH in a patient with metastatic prostate cancer on chronic low dose prednisone therapy and a history of chemotherapy and radiation. CASE PRESENTATION: A 72 year old male presented with fever, cough and altered mental status in the setting of metastatic prostate cancer with bony and liver metastasis diagnosed nine years ago. He underwent palliative radiation five weeks prior to admission and was being treated with Abiraterone and Prednisone 10mg daily. The patient was febrile, tachypnic and tachycardic. Physical exam revealed a lethargic male with diffuse crackles on lung auscultation. Chest X-ray revealed bibasilar interstitial opacifications. Rapid flu nasal swab returned influenza A positive and Oseltamivir was started in addition to empiric antibiotics. CT chest (figure 1) showed diffuse bilateral airspace disease. The patient subsequently developed increased oxygen requirements with PaO2/FiO2 of 59 and hemolytic anemia requiring transfusion. Repeat chest x-ray (figure 1) showed worsening diffuse interstitial infiltrates and nodular densities. He was electively intubated and transferred to the ICU. Low tidal volume ventilation was initiated and bedside bronchoscopy was performed revealing diffuse airway petechiae. Lingular bronchoalveolar lavage returned blood without clearance after multiple sequential aliquots (figure 2). Cell count showed 700 WBC (50% neutrophils, 16% lymphocytes and 34% monocytes) and 150,000 RBC. Pathology returned with pigment-laden macrophages. Bronchial cultures were negative for bacteria, fungi and viruses. Rheumatologic serology was negative. Patient suffered a prolong ICU stay but was ultimately successfully extubated. DISCUSSION: Although Influenza A is one etiology of alveolar damage which may result in DAH, many medical professionals are not aware that the presence of malignancy may compound the risk for this complication. There are few case reports of H1N1 pneumonia complicated by alveolar hemorrhage. Patients with malignancies are more susceptible for the acquisition of infections than the general population. To that extent, disruptions in both innate and acquired immunity place cancer patients at higher risk for complications related to infectious organisms. CONCLUSIONS: Our intention is to shed light on the connection between influenza A and DAH in immunocompromised patients so that prompt and appropriate treatment can be initiated in order to reduce morbidity and mortality associated with this disease process. Reference #1: Hajjar, L. A, et al. (2010). Severe novel influenza A (H1N1) infection in cancer patients.Annals of Oncology, 21, 2333-2341. Reference #2: Mussi von Ranke, F, et al.(2013). Infectious Diseases Causing Diffuse Alveolar Hemorrhage in Immunocompetent Patients: A State-of-the-Art Review. Lung,191, 9-18. DISCLOSURE: The following authors have nothing to disclose: Clarissa Castanon, Christopher Jordan, Stephen Milan, Saleem Shahzad No Product/Research Disclosure Information