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Catastrophic Pulmonary Collapse

 

H1N1

Case Study: Treatment of Necrotizing Pneumonia from Influenza and MRSA

Twenty-eight-year-old female presented to a New York hospital with progressive fever, chest pain and sore throat, despite Tamiflu use. She tested positive for H1N1 influenza, was admitted to the intensive care unit and started on antibiotic therapy. Three days later, she was intubated and found to have developed a right pneumothorax, for which a right chest tube was placed. She was subsequently diagnosed with methicillin-sensitive staphylococcus aureus (MRSA) superinfection, and developed subcutaneous emphysema with suspected acute respiratory distress syndrome (ARDS). A tracheostomy was performed, and she was placed on mechanical ventilation. Necrotizing pneumonia was suspected, and bronchoscopy produced P. mirabilis in the bronchial wash. CT showed a bleb in the left lower lung. Surgical excision was recommended after the patient’s respiratory status was improved. She was transferred to Cleveland Clinic for further evaluation.

Treatment

The patient had developed large fistulae in the lung that began rupturing, causing uncontrollable air leakage. We maintained antibiotic therapy and performed a left thoracotomy with repair of bronchopleural fistula and decortication. Her antibiotic regimen was changed, and a third agent started when she developed new-onset fever. A chest CT showed no new collections. Fever resolved and the patient stabilized. Two antibiotics were stopped, and after nearly seven weeks’ hospitalization, the patient was discharged to rehab with orders to continue one antibiotic for three weeks.

Outcome

The patient recovered from her catastrophic illness characterized by uncontrolled air leak, empyema and respiratory failure. She returned to work full time and is able to exercise on a regular basis. A CT scan performed one year after discharge demonstrated nearly full expansion of her left lung, with resolution or consolidation of many of the pneumatoceles that had been present. Minor left pleural thickening is seen, but there is no significant adenopathy.

She continues to experience episodes of recurrent lung infection characterized by cough and dyspnea every four to six weeks, requiring antibiotics and/or corticosteroids for these episodes. Resection of the bronchiectasis has not been advised, as the patient appears fit and healthy.

Reviewed: 11/13

Non-critical demographic information has been changed to protect the anonymity of the individual and no association with any actual patient is intended or should be inferred.

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