SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumothorax (PTX) is the presence of air in the pleural space causing compression of the lungs, leading to subsequent respiratory distress. Spontaneous PTX develops in the absence of trauma and is classified as primary or secondary if underlying lung disease is noted. Rarely, a patient can develop simultaneous bilateral spontaneous pneumothoraces, which can result in a life-threatening state requiring intubation or resuscitation. Some sources list this occurrence to be about 1-1.9% of spontaneous pneumothorax-related cases. CASE PRESENTATION: A 38-year-old female with a history of Type 1 DM and ESRD on peritoneal dialysis, presented with a cough, fever, and significant dyspnea. CXR showed bilateral lung consolidation consistent with pneumonia. She was admitted to the ICU for acute hypoxia. Broad spectrum antibiotics were started. Blood and sputum cultures grew methicillin resistant streptococcus aureus (MRSA). Her blood cultures also grew VRE and the antibiotics were changed appropriately and PD catheter was removed. Despite overall clinical improvement, her respiratory status declined due to worsening hypoxia which was attributed to mucus plugging due to her inability to initiate a good cough reflex. Aggressive pulmonary toileting resulted in no improvement. A repeat CXR was done and showed bilateral pneumothoraces significantly worse on the left side, without evidence of tracheal shift. Urgently, a chest tube was inserted on the left side and placed to suction, with follow up imaging showing improvement of the left PTX, but significant worsening of the right PTX. This prompted another chest tube placement on the right side. Repeat CXR showed improvement in both pneumothoraces. Despite this, she failed multiple attempts at discontinuing her chest tubes due to reaccumulating air. Invasive procedures were avoided due to her persistent pneumonia and critically ill condition. The patient and family decided to pursue comfort care measures. DISCUSSION: In a Taiwan study of Spontaneous Secondary Pneumothoraces, a bacterial etiology was identified in about 11% of patients. The pathogenesis was postulated to be to be associated with migration of the bacteria into the pleural space, leading to empyema. It is hypothesized the patients developed the pneumothoraces secondary to bilateral necrotizing bacterial pneumonia. The causative bacterial agents were Staphylococcus, Klebsiella, Pseudomonas, Streptococcus Pneumoniae, and Anaerobic organisms. CONCLUSIONS: Since our patient had MRSA pneumonia, it can be inferred that this was the culprit of her pneumothoraces as there was no other cause. Akcam et al reported a mortality rate of 54% in patients with SBSP within the first 6 months of follow-up. Hence, it is important to have a high suspicion for SBSP in patients who have respiratory decline after initial improvement. Reference #1: Akcam, Tevfik Ilker, et al. “Analysis of the Patients with Simultaneous Bilateral Spontaneous Pneumothorax.” The Clinical Respiratory Journal, U.S. National Library of Medicine, Mar. 2018, www.ncbi.nlm.nih.gov/pubmed/28544468. Reference #2: Athanassiadi K, Kalavrouziotis G, Loutsidis A, et al. Treatment of spontaneous pneumothorax: ten-year experience. World J Surg 1998;2013:803–6 [PubMed] Reference #3: Aydin, Y., Turkyilmaz, A., Intepe, Y. S., & Eroglu, A. (2010). Simultaneous bilateral spontaneous pneumothorax: a rare emergency clinical condition. The Eurasian Journal of Medicine, 42(1), 5–8. https://doi.org/10.5152/eajm.2010.02 DISCLOSURES: No relevant relationships by Lilibeth Jauregui, source=Web Response No relevant relationships by Navneet Kaur, source=Web Response No relevant relationships by Enoemem Okpokpo, source=Web Response