CHYLOPYOPNEUMOTHORAX IN A PATIENT WITH RHEUMATOID LUNG DISEASE

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: While non-tuberculous mycobacteria (NTM) can cause a wide spectrum of human disease, their association with pleural effusion is unusual (1). We describe a case of Mycobacterium fortuitum empyema in a patient with rheumatoid lung disease who presented with spontaneous secondary pneumothorax. Incidentally, his pleural fluid also revealed chylomicrons suggesting chylothorax. CASE PRESENTATION: A 52 yo male with history of Rheumatoid Arthritis (RA), IV methamphetamine use, chronic asymptomatic bilateral pulmonary nodules and pleural effusions (presumed rheumatoid lung disease) presented with shortness of breath and cough for 5 days. He was hemodynamically stable except for mild tachycardia. Chest X ray revealed right sided pneumothorax. A 9 Fr anterior chest tube was placed with improvement in pneumothorax. Subsequently, milky fluid started draining from the tube. Fluid analysis showed: pH 7.61, RBC 50,000/cu.mm, WBC 64,000/cu.mm with 94% neutrophils, glucose 5 mg/dl, LDH 4344 u/L, protein 5.0 g/dL, amylase 30 U/L, triglyceride 114 mg/dL, ADA 111.8 U/L, chylomicrons present. CT scan showed pulmonary nodules some of which increased in size and cavitated when compared to old scans. Pleural fluid cultures grew mycobacterium within 48 hours which eventually speciated as M. fortuitum. VATS guided right pleural biopsy was performed and multiple biopsy samples grew M. fortuitum. Of note, the same organism grew in his sputum samples as well. DISCUSSION: Rapidly growing mycobacteria rarely cause pulmonary infection, and when it does occur, it is typically from abscessus (2). Pulmonary infection may occur from M. fortuitum, in a patient with known underlying lung disease or immunosuppression (3). Our patient had known asymptomatic pleural effusion and bilateral pulmonary nodules. He presented with spontaneous pneumothorax associated with increase in size of nodules and cavitation. He was on leflunomide and hydroxychloroquine for RA and has also been getting steroids intermittently for RA flares, last given 2 months prior to presentation. It is possible that underlying lung disease and immunosuppression predisposed him to develop M. fortuitum infection, which in turn lead to cavitation of peripheral nodules and pneumothorax. Incidentally, pleural fluid testing also revealed chylomicrons, confirming component of chylous effusion This case suggests that rheumatoid lung disease, especially in setting of steroid therapy is a risk factor for NTM infection, and development of such infection may be heralded by an acute complication such as pneumothorax. CONCLUSIONS: NTM are rarely associated with pleural disease. They should be considered in the differential when an immunocompromised individual with chronic lung disease presents with acute worsening. We describe a rare association of rheumatoid lung disease with M. fortuitum pulmonary infection which lead to acute presentation with chylopyopneumothorax. Reference #1: Johnson MM, Odell JA. Nontuberculous mycobacterial pulmonary infections. J Thorac Dis. 2014;6(3):210-20. Reference #2: Griffith DE, Girard WM, Wallace RJ Jr. Clinical features of pulmonary disease caused by rapidly growing mycobacteria. An analysis of 154 patients. Am Rev Respir Dis. 1993 May;147(5):1271-8. Reference #3: Park S, Suh GY, Chung MP, Kim H, Kwon OJ, Lee KS, Lee NY, Koh WJ. Clinical significance of Mycobacterium fortuitum isolated from respiratory specimens. Respir Med. 2008 Mar;102(3):437-42. Epub 2007 Nov 9. PubMed PMID: 17997087. DISCLOSURES: No relevant relationships by Spyridon Fortis, source=Web Response No relevant relationships by Vikas Koppurapu, source=Web Response no disclosure on file for Matthew McGee; No relevant relationships by Tayyab Rehman, source=Web Response No relevant relationships by Roger Struble, source=Web Response