PILL-INDUCED PNEUMONITIS PRECIPITATING GROSS HEMOPTYSIS BY ASPIRATED ANTICOAGULANT MEDICATION

Abstract

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pill pneumonitis (PP) is described as pulmonary inflammation and fibrosis secondary to the aspiration of pills. Those having dysphagia are at the highest risk for aspiration include neurologic impairment, anatomic deformity, and oropharyngeal dysfunction. The epidemiology of this condition is ill-defined to date given the scarcity of its diagnosis. Herein, we present a unique case of pill pneumonitis secondary to anticoagulant aspiration leading to gross hemoptysis. CASE PRESENTATION: A 26-year-old male, with a 2-year remote history of MVA complicated by right upper extremity DVT on Rivaroxaban, presented with a two-day history of gross hemoptysis with concurrent cough and dyspnea. PMH is otherwise unremarkable. The patient recalled choking a few days prior on his medications. Upon presentation, he had stable vital signs and a physical exam remarkable for mild left-sided rales.Laboratory workup demonstrated no leukocytosis and no significant change in hemoglobin. CT angiogram demonstrated peribronchial patchy consolidation with scattered ground-glass opacities; With reactive mediastinal and hilar lymphadenopathy. The patient was admitted for evaluation of new-onset hemoptysis and a subsequent bronchoscopy discerned diffuse patchy erythematous friable mucosa with foreign body particulates, most notably in the left mainstem bronchus. Otherwise, all accompanying testing was unyielding included infectious and autoimmune panels and tissue biopsies. The patient's Rivaroxaban was discontinued and the Ultrasound of the upper extremity showed no evidence of DVT. He received a course of steroids and antibiotics. The patient's gross hemoptysis resolved by the second day of hospitalization. DISCUSSION: PP is a serious complication to FBA and the acute onset of cough, wheezing, and dyspnea should raise suspicion in patients without other suggestive causes. These include pneumonia, congestive heart failure, or trauma. This case is noteworthy due to the patient's aspiration of an anticoagulant leading to an acute onset of pill pneumonitis with significant gross hemoptysis. A high degree of suspicion is needed to initiate early and aggressive diagnostic and interventional treatment, and the threshold of suspicion should be lowered in patients with a greater risk of aspiration. Our patent did not have risk factors for dysphagia, however, unnecessary use of anticoagulant therapy led to the acute progression of this patient's clinical presentation. Furthermore, management of pill pneumonitis is based on early and aggressive bronchoalveolar lavage and foreign body removal, which has shown to reduce disease progression and reverse inflammatory changes. CONCLUSIONS: This case describes a novel cause of PP, as no previous case describes aspiration of anticoagulant medication and emphasizes the importance of early diagnosis and proper anticoagulant use as a means of preventing unforeseen complications. REFERENCE #1: Hill, S. N., Main, A. N., & Fuggle, W. J. (1988). Covert inhalation of tablet causing fatal pneumonia. Postgraduate Medical Journal, 64(747), 66-67. doi:10.1136/pgmj.64.747.66 REFERENCE #2: Hu, X., Lee, J. S., Pianosi, P. T., & Ryu, J. H. (2015). Aspiration-related pulmonary syndromes. Chest, 147(3), 815-823. doi:10.1378/chest.14-1049 REFERENCE #3: Lee, P., Culver, D. A., Farver, C., & Mehta, A. C. (2002). Syndrome of iron pill aspiration. Chest, 121(4), 1355-1357. doi:10.1378/chest.121.4.1355 DISCLOSURES: No relevant relationships by Connor Kerndt, source=Web Response no disclosure on file for Shahid Mohammed; No relevant relationships by Mitchelle Zolotarevsky, source=Web Response