STAPHYLOCOCCUS AUREUS PNEUMONIA AND EMPYEMA AS A COMPLICATION OF E-CIGARETTE USE

Abstract

SESSION TITLE: Medical Student/Resident Tobacco Cessation and Prevention Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Electronic-cigarettes (e-cigarettes), popularized in the late 2000s, were introduced as a safer alternative to traditional tobacco cigarettes. However, emerging data suggests a considerable risk for developing pulmonary diseases in users of e-cigarettes. Despite this concern, e-cigarette use is on the rise with up to 20% of Americans aged 25 to 44 now using e-cigarettes [1]. We present an interesting case which explores the relationship between e-cigarettes and the development of methicillin sensitive Staphylococcus aureus (MSSA) pneumonia. CASE PRESENTATION: A 38-year-old female was admitted with a five-day history of fever, dyspnea, and a productive cough. Her medical history was only notable for daily use of nicotine products via an e-cigarette. Vital signs on arrival revealed a temperature of 37.9 degrees centigrade, tachycardia with a pulse rate of 133 beats per minute, and tachypnea with a respiratory rate of 26 breaths per minute. She was able to maintain appropriate oxygen saturations on room air. Physical examination was notable for diminished air movement in left lower lung base. Admission labs were notable for a white blood cell (WBC) count of 12.83 x10(9)/L, and a procalcitonin of 11.3 ng/mL. Notably, both urine streptococcus and legionella antigens were negative. A chest radiograph demonstrated a left lower lobe opacity with associated effusion [Figure 1], which was also present on a computed tomography scan of her chest [Figure 2A-B]. Therefore, a diagnostic thoracentesis was performed from which pleural fluid analysis revealed a pH of 6.6, lactate dehydrogenase of 1,478 units/L, protein of 4.7g/dL, and WBC count of 5,082 cells/mL. Subsequent cultures from both the pleural fluid and sputum grew MSSA. The patient was started on empiric antibiotics and had a left-sided chest tube inserted for drainage of her empyema. Given the presence of loculations, additional therapy with intrapleural dornase alpha and tissue plasminogen activator was initiated. The patient clinically improved, her chest tube was removed, and she was discharged home to complete four weeks of nafcillin. The patient reported continued recovery and success in quitting e-cigarettes at her subsequent follow up. DISCUSSION: As the long-term effects of e-cigarette use become more evident, it is clear that they pose significant risks to patients. E-cigarettes decrease host ability to fight infection by promoting virulence in bacterial colonizers of the airways and by increasing pro-inflammatory markers [2]. Furthermore, vapors from e-cigarettes have been implicated in increasing biofilm formation. Biofilms lead to an increase of virulence in a variety of lung pathogens, including Staphylococcus aureus [3]. CONCLUSIONS: Clinicians should be aware of an increase in virulence from bacterial pathogens (particularly MSSA) responsible for community acquired bacterial pneumonia amongst e-cigarette users. Reference #1: Hwang, John H., et al. “Electronic cigarette inhalation alters innate immunity and airway cytokines while increasing the virulence of colonizing bacteria.” Journal of molecular medicine 94.6 (2016): 667-679. Reference #2: Gilpin, Deirdre F., et al. “Electronic cigarette vapour increases virulence and inflammatory potential of respiratory pathogens.” Respiratory Research 20.1 (2019): 267. Reference #3: Shi, L., Wu, Y., Yang, C. et al. Effect of nicotine on Staphylococcus aureus biofilm formation and virulence factors. Sci Rep 9, 20243 (2019). https://doi.org/10.1038/s41598-019-56627-0 DISCLOSURES: No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Armin Krvavac, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by Richard Swaney, source=Web Response