Contributed by James R Davie, MD PhD, Octavia Graur MD PhD, and John Sheaffer, MS
Published on line in April 2000
The patient was a 75-year-old woman with a past medical history significant for a 6-month history of cryoglobulinemia with vasculitis, congestive heart failure, hypertension, cryptogenic cirrhosis, peripheral vascular disease, chronic renal insufficiency, anemia, degenerative joint disease, and diverticulitis. Beginning three days prior to admission, the patient had been initiated on Prednisone and interferon for treatment of cryoglobulinemia. She presented with chief complaint of increasing shortness of breath for one week.
Auscultation of the chest was significant for bilateral coarse crackles in the lower one-third of the lung fields. Chest X-ray showed cardiac enlargement with pulmonary edema and a right mid-lung pneumonic infiltrate. A review of the chest X-rays for the prior six-month period revealed a progressive interstitial pattern, believed to represent a pulmonary vasculitis/fibrosis secondary to cryoglobulinemia. Laboratory data on admission was significant for a hemoglobin of 9 gm/dl, hematocrit 25.1%, platelets 137,000, WBCs 32,600 (86% polys, 9% bands).
On admission, the patient was continued on interferon and oral prednisone for her vasculitis/cryoglobulinemia. Antibiotics (Cefuroxime and Azithromycin) were added to her regimen for presumptive diagnosis of pneumonia.
The patientís respiratory function improved readily over the first three weeks following admission. However, this was followed by a slow increase in WBC count and progressive respiratory failure which required intubation on the 23rd day following admission.
A broncho-alveolar lavage showed blood-stained fluid consistent with alveolar hemorrhage. A Gram stain of the bronchial washings showed many red blood cells, few white blood cells and no organisms. Bacterial cultures of the bronchial washings grew rare Pseudomonas aeruginosa and rare coagulase-negative staphylococci. Mycobacterial and fungal cultures of the bronchial washings were negative.
The patient was treated for presumptive sepsis by adding piperacillin to her ongoing cefuroxime regimen. Nevertheless, she became hemodynamically unstable and expired of presumptive sepsis on the 26th day following admission.
An autopsy was performed. Autopsy spleen cultures were positive for Enterobacter faecium and Pseudomonas aeruginosa; blood cultures were positive for Enterobacter faecium and Torulopsis glabrata; lung cultures were negative for growth after two days. Sectioning the left lung reveals an area of gray consolidation measuring 4.5 cm in its greatest dimension located in the left lower lobe. Sectioning the right lung revealed an area of gray consolidation measuring 6.0 cm in the right upper lobe.
MICROSCOPIC FINDINGS (LUNG)