BRONCHOPLEURAL FISTULA COMPLICATION OF INTRAPLEURAL TPA/DORNASE IN PRESENCE OF LUNG ABSCESS

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A short course intrapleural instillation of tissue plasminogen activator (tPA) and recombinant human deoxyribonuclease I (dornase alfa) is a highly safe and effective treatment for complicated parapneumonic effusions (CPE) and empyema. It improves drainage and reduces surgical referral as well as hospitalization length [1-3]. Clinical experiences of dual tPA/dornase therapy and ensuing rare complications are cumulating. CASE PRESENTATION: A 49 year old female with past medical history of hypertension, extensive tobacco use, and history of IV drug use presented with complaints of right sided chest pain, productive cough with blood tinged sputum, and weight loss for 2 weeks. Vitals were normal and physical exam only significant for decreased right chest breath sounds. An initial CT chest demonstrated right sided pleural effusion with air-fluid level and a cavitary lesion of 7 cm suggestive of lung abscess. She was admitted to the medical floor with antibiotics. On day 2, a 10F pigtail catheter was placed with frank pus evacuated. Pleural fluid analysis showed WBC >800K cells/μL, glucose 10 mg/dL, LDH >40K IU/L, protein 3.1 gm/dL. The cultures of the pleural fluid grew Streptococcus intermedius. Repeat CT demonstrated chest tube in position without communication between empyema and lung abscess.On day 4, two rounds of intrapleural 10mg tPA and 5mg dornase alfa were administered to facilitate drainage. The next day, an additional 250 mL of bloody output was noted from the pigtail catheter with development of a new air leak. A repeat CT chest revealed improvement in the right sided empyema and subcutaneous emphysema. The visualization of previously described cavitary lesion was noted to be open to the pleural cavity.She was transferred to the ICU for close observation and management due to development of a bronchopleural fistula (BPF). A larger 16F chest tube was placed to aid drainage and reduce subcutaneous emphysema. After 2 days, the patient was no longer experiencing air leak and subsequently had chest tube removed on hospital day 7. She was discharged home with an extended course of oral amoxicillin-clavulanic acid and to follow-up in clinic. DISCUSSION: This case describes a complication that can happen when using intrapleural tpa/dornase therapy in presence of lung abscess which can lead to BPF which can result from abscess rupture into the pleural cavity. As for our literature review, we could not find any reported cases of similar complications of fistula development, however, it was noted bleeding complication with prolonged tpa/dornase use. CONCLUSIONS: Standard 3 day treatment is effective in reducing surgical referral and intervention, however, it is important to appreciate complications that can arise from therapy in presence of lung abscesses. There should close monitoring of chest tube output upon utilization of tpa/dornase therapy. REFERENCE #1: Rahman, N.M., et al., Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med, 2011. 365(6): p. 518-26. REFERENCE #2: Majid, A., et al., Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience. Ann Am Thorac Soc, 2016. 13(9): p. 1512-8. REFERENCE #3: Piccolo, F., et al., Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection. J Thorac Dis, 2015. 7(6): p. 999-1008. DISCLOSURES: No relevant relationships by Mohammed Al-Ourani, source=Web Response No relevant relationships by Rami Batarseh, source=Web Response No relevant relationships by Belete Desimmie, source=Web Response No relevant relationships by Anup Kumar, source=Web Response No relevant relationships by Kelsey Marshall, source=Web Response