SESSION TITLE: Critical Care 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: The incidence of acute myopericardtis (AMP) is estimated to be 1 in 10 cases per 100,000 persons, with acute viral infections accounting for most (1% to 5%) of the cases (1). Diffuse Alveolar Hemorrhage (DAH) has a spectrum of disorders associated with it, systemic vasculitis being the most frequent one (2). However, Group A streptococcus (GAS) and Respiratory syncytial virus (RSV) are rarely reported as causative pathogens of AMP or DAH. We report a case of GAS and RSV infection complicated by AMP and DAH. CASE PRESENTATION: A 36-year-old male with Addison's disease on hydrocortisone and fludrocortisone, presented with lethargy and shortness of breath for 2 days. His vital signs were significant for a temperature of 101.7°F and blood pressure of 78/53 mm/Hg. On physical exam he had neck edema, palpable tender cervical lymph nodes and tonsillar exudates bilaterally. Centor score was 4.His labs were remarkable for a leukocytosis, lactic acidosis and elevated creatinine at 1.7mg/dl. The rapid streptococcal test and RSV polymerase chain reaction were positive. Computed tomography of the neck revealed severe edema of bilateral palatine tonsils extending to aryepiglottic folds, high-grade stenosis at the level of the nasopharynx and bilateral cervical lymphadenopathy. The patient was emergently intubated for airway protection. He was administered broad spectrum antibiotics and stress dose steroids and transferred to the intensive care unit. Despite initial treatment, he clinically deteriorated and progressed to shock. An Electrocardiogram showed diffuse ST- segment elevation and PR-segment depression in V5, V6 and lead II. Troponin I was elevated at 17ng/ml. A transthoracic echocardiogram was performed which showed diffusely hypokinetic left and right ventricle suggesting a component of AMP. Colchicine was initiated. Due to progressive hypoxemia, the patient underwent bronchoscopy which revealed increasing red blood cells in sequential bronchoalveolar lavage aliquots. During a prolonged ICU course, there was gradual clinical improvement with resolution of shock, AMP and DAH. The patient was successfully extubated and had a complete recovery. DISCUSSION: GAS and RSV are frequently encountered infections that typically have an innocuous course in immunocompetent adults. However, there is a paucity of literature describing RSV or GAS in correlation with fulminant AMP and DAH. AMP and DAH are medical emergencies that can be fatal if left untreated. High index of suspicion and prompt diagnosis and treatment are crucial for complete recovery. CONCLUSIONS: We not only depict rare infectious entities through our case, but we stress the importance of considering AMP and DAH as potential life threatening complications of RSV and DAH, especially in immunocompromised adults. Reference #1: Bhaduri-McIntosh S, Prasad M, Moltedo J, Vαzquez M. Purulent pericarditis caused by group A streptococcus. Texas Heart Institute Journal. 2006;33(4):519. Reference #2: Park MS. Diffuse Alveolar Hemorrhage. Tuberculosis and Respiratory Diseases. 2013;74(4):151-162. https://doi.org/10.4046/trd.2013.74.4.151. DISCLOSURES: No relevant relationships by DHRUBAJYOTI BANDYOPADHYAY, source=Web Response No relevant relationships by Karishma Bhatia, source=Web Response No relevant relationships by Susannah Kurtz, source=Web Response No relevant relationships by James Salonia, source=Web Response
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