SESSION TITLE: Chest Infections 2 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) represents a life-threatening complication of many respiratory infections. We present a case of Influenza A pneumonia associated with DAH, an uncommon but likely unrecognized complication. CASE PRESENTATION: An 80-year-old female was admitted with lethargy, dyspnea and chest pain. Medical history included end stage renal disease and compensated systolic heart failure. On examination, she was afebrile with bilateral basal inspiratory crackles. Laboratory evaluation was unremarkable apart from mild anemia. Chest-roentgenogram revealed retro-cardiac infiltrate; computed tomography of chest showed left lower lobe consolidation and scattered ground glasses opacification. The patient required intubation and pressors for acute hypoxic respiratory failure and septic shock. Nasopharyngeal swabs rapid testing was positive for influenza A. She received vancomycin, piperacillin-tazobactam, azithromycin and oseltamivir. Bronchoscopy showed bilateral airway erythema and diffuse bleeding, and no endobronchial lesions. Bronchoalveolar lavage (BAL) of the left lower lobe had progressively bloody returns, consistent with DAH (Fig 1). Respiratory, urine and blood cultures were negative. Methylprednisolone 250 mg daily was started, with improvement in oxygenation. Repeat bronchoscopy 2 days later revealed normal mucosa and no mucosal bleeding (Fig 2). The patient's clinical status continued to deteriorate and she died two weeks after admission. DISCUSSION: In immunocompromised patients, the main infectious diseases that cause DAH are cytomegalovirus, adenovirus, invasive aspergillosis, Mycoplasma, Legionella, and Strongyloides. In immunocompetent patients, the infections most frequently causing DAH are influenza A (H1N1), dengue, leptospirosis, malaria, and Staphylococcus aureus infection (1). Higher fatality has been reported in patients with influenza A complicated by DAH (2). Pathological review of the influenza A (H1N1) 2009 pandemic reported mild-intense alveolar hemorrhage and intraalveolar edema (3). Advanced age and the presence of significant co-morbidities may predispose a patient not only to the development of influenza, but also to one if its most feared complications. The use of steroids, while controversial, may be a useful adjunct in patients with influenza A pneumonia and DAH. CONCLUSIONS: Elderly patients with significant co-morbidities may be at increased risk of developing DAH with influenza A pneumonia. Clinicians should maintain a high suspicion for DAH, as it may increase fatality rate. Steroids, in addition to supportive care, may have a role in management. Reference #1: von Ranke FM, Zanetti G, Hochhegger B, Marchiori E. Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients: a state-of-the-art review. Lung. 2013 Feb;191(1):9-18 Reference #2: Prasad HB, Puranik SC, Kadam DB, Sangle SA, Borse RT, Basavraj A, Umarji PB, Mave V, Ghorpade SV, Bharadwaj R, Jamkar AV, Mishra AC (2011) Retrospective analysis of necropsy findings in patients of H1N1 and their correlation to the clinical features. J Assoc Physicians India 59:498-500 Reference #3: Soto-Abraham MV, Soriano-Rosas J, Díaz-Quiñónez A, Silva-Pereyra J, Vazquez-Hernandez P, Torres-López O, et al. Pathological Changes associated with the 2009 H1N1 virus. N Engl J Med 2009;361(20):2001-2003. DISCLOSURES: No relevant relationships by Gilda Diaz-Fuentes, source=Web Response No relevant relationships by OMESH TOOLSIE, source=Web Response