CHALLENGING CASE OF RECURRENT PNEUMONIA IN A PATIENT WITH COAL WORKER’S PNEUMOCONIOSIS

Abstract

SESSION TITLE: Medical Student/Resident Occupational and Environmental Lung Diseases SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Coal worker’s pneumoconiosis (CWP) is a chronic occupational lung disease leading to irreversible lung damage. Severe forms result in progressive massive pulmonary fibrosis (PMF). We will be discussing a case of an elderly male with CWP and recurrent episodes of pneumonia. CASE PRESENTATION: 72-year-old male with past medical history significant for working in the coal mines for about 27 years with a diagnosis of CWP and PMF. PFTs showed mixed obstructive and restrictive defects. He had multiple hospitalizations for sepsis secondary to recurrent pneumonia. His symptoms consisted of productive cough without hemoptysis, chills, pyrexia, worsening dyspnea and hypoxia. CT chest showed severe CWP with PMF, right lower lobe consolidation and a cavitary mass in the left upper lobe. The patient had been diagnosed with ESBL positive E. coli pneumonia and treated with IV Ertapenem for 4 weeks. He was readmitted to the hospital shortly after completing this treatment and was diagnosed with Streptococcus pneumoniae bacteremia and pneumonia, for which he was treated with IV Rocephin. CT guided biopsy of the cavitary mass was negative for malignancy, but the procedure was complicated by pneumothorax requiring chest tube and pleurodesis by general surgery. Bronchoscopy with EBUS was also performed which was again negative for malignancy and AFB, but one BAL sample showed prominent eosinophils. CBC also showed eosinophilia. IgE level was elevated at 1,909; his IgA, IgG, and IgM levels were all within normal limits. Quantiferon TB gold was negative. Patient’s Strongyloides antibodies were elevated at 1.66 and he was diagnosed with Strongyloides stercoralis hyperinfection syndrome. He was treated with one dose of Ivermectin. Patient was followed in the outpatient pulmonology clinic and had no further hospitalizations due to pneumonia. DISCUSSION: Most common risk factors for Strongyloides hyperinfection syndrome includes being in an institutionalized population or living in rural areas. The mode of transmission is through contact with contaminated soil. Activities that increase contact include walking with bare feet, contact with human waste, and occupations that increase contact with soil. Coal miners are at higher risk of infections such as, Strongyloides. Most cases reported are due to chronic immunosuppression secondary to chronic steroid use. Even though our patient was not on chronic steroids, he had received many courses of steroid therapy during his numerous hospitalizations. The chronic changes of PMF can add more challenges and increase the complexity of the clinical presentation and may delay timely diagnosis and treatment of this uncommon cause of recurrent infections. CONCLUSIONS: The workup for recurrent pneumonia in patient's with progressive massive fibrosis should include the evaluation for Strongyloides hyperinfection syndrome in the appropriate clinical context. Reference #1: Arnold, Carrie. "A Scourage Returns: Black Lung in Appalachia." Environmental Health Perspective (2016): A13-A18. Epublished January 1, 2016. Reference #2: Asdamongkol N, Pornsuriyasak P, Sungkanuparph S. "Risk factors for strongyloidiasis hyperinfection and clinical outcomes." The Southeast Asian Journal of Tropical Medicine and Public Health (2006): 875-884. Reference #3: Gourahari Pradhan, M.D.,1 Priyadarhini Behera, M.D.,1 Manoj Kumar Panigrahi, M.D.,corresponding author1 Sourin Bhuniya, M.D.,1 Prasanta Raghab Mohapatra, Jyotirmayee Turuk, and Srujana Mohanty, M.D. et. al. "Pulmonary Strongyloidiasis Masquerading as Exacerbation of Chronic Obstructive Pulmonary Disease." Tuberculosis and Respiratory Disease (2016): 301-311. Epublished October 5, 2016. DISCLOSURES: No relevant relationships by Haytham Adada, source=Web Response No relevant relationships by Mahmoud Amarna, source=Web Response No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Rabab Elmezayen, source=Web Response No relevant relationships by Sana Yakoob, source=Web Response