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Clinical Infection & Immunity

Case Report

Volume 4, Number 1, March 2019, pages 16-18

A Rare Case of Organizing Pneumonia

Enterococcus faecalis and Enterococcus faecium are main species under genus enterococcus. They are gram-positive facultative anaerobic cocci that habitat human gastrointestinal (GI) tract. Emergence of multidrug resistant species especially in health care setting has been in rise, producing challenge for effective treatment by health care professionals. Prolonged hospital state, debilitated conditions, immunocompromised state, previous antibiotic can help these normal habitants to proliferate, translocate to blood stream and acquire multidrug resistant state causing disseminated infection.

A 71-year-old male with past medical history of hypertension, diabetes mellitus and dyslipidemia presented to emergency room (ER) for generalized weakness, poor oral intake and shortness of breath. X-ray of chest showed left upper lobe opacity and effusion. Two weeks prior to this he had workup done for persistent nausea and vomiting which included endoscopy, colonoscopy and laparoscopic cholecystectomy. Hospital course was complicated by intra-abdominal abscess that was successfully treated with intravenous (IV) then oral antibiotics. General lab work in emergency showed leukocytosis of 13,000 with left shift. He was diagnosed with hospital-acquired pneumonia and parapneumonic effusion. A bedside ultrasound-guided thoracentesis was performed. Analysis of fluid showed exudative effusion with normal pH of 8. He was started on broad spectrum antibiotics which was subsequently deescalated to oral antibiotics within 48 h of negative blood and pleural fluid culture. On the third day, he was discharged on oral antibiotic with outpatient pulmonary clinic follow-up. However, in 1 week he returned back to ER with the same complaints.

This time computed tomography (CT) scan of chest was done to evaluate for complicated pneumonia. Scan (Fig. 1) showed 7 cm left upper lobe mass with reaccumulation of left effusion. Blood culture this time was positive for Enterobacter aerogenes. Left chest thoracostomy with large bore chest tube was placed to drain the effusion. He was then started on carbapenem along with fluoroquinolones to cover for Enterobacter pneumonia. His chest tube continued draining about 500 - 1,000 mL of clear exudative fluid for 3 to 4 days. In subsequent days, he stabilized clinically when bronchoscopy and transbronchial biopsy of the mass was planned. On bronchoscopy, no endobronchial lesions were seen. Transbronchial biopsies were performed from left upper lobe, and bronchial washings were sent for analysis.

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Figure 1. CT scan showed the 7 cm left upper lobe mass with left pleural effusion.

Both cytology from bronchial wash and transbronchial biopsy were in conclusive. He then underwent CT-guided percutaneous needle biopsy of the mass. However, it showed predominantly necrotic cells. He continued receiving antibiotics but on daily chest X-rays, the mass continued getting worse. In 1-week repeat CT scan (Fig. 2), it showed further increase in the mass which was now 8.8 cm, with necrosis.

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Figure 2. CT scan showed the 8.8 cm left upper lobe necrotic mass with pleural effusion.

Due to uncertainty of the case, pulmonologists and cardiothoracic surgeons came with joint decision to proceed with a positron emission tomography (PET) scan. ON PET (Fig. 3a, b) a heterogeneous FDG avid 7.8 × 6.7 × 8.8 cm partially necrotic left upper lobe mass like consolidation (SUV max 10.1) and nonspecific FDG avid mediastinal and hilar lymph nodes were present.

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Figure 3. (a) Left upper lobe necrotic mass. (b) FDG avid left upper lobe mass.

Transbronchial biopsy of mediastinal lymph nodes under endobronchial ultrasound was then attempted. Subcarinal, left hilar and right paratracheal lymph nodes were biopsied along with repeat biopsy of left upper lobe mass. However, the result was still inconsistent.

Finally, he had to go for VATS-guided left upper lobe mass biopsy which showed histological pattern of organizing pneumonia. The lung tissue culture grew vancomycin-resistant Enterococcus faecium. He was then started on linezolid. A repeat CT scan within 1 week showed decrease in size of the mass with development of internal air bronchogram (Fig. 4).

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Figure 4. Left upper lobe mass with internal bronchogram.

Enterococci have been increasingly identified as a cause of nosocomial infection especially in old and debilitated patients [1, 2]. There have been emerging cases of multidrug resistant isolates to commonly used antibiotics as penicillin, cephalosporins, aminoglycoside and vancomycin.

This allows selective growth advantage while competitive organisms, susceptible to antibiotics are suppressed. Enterococci commonly cause urinary tract infection, bacteremia, endocarditis, wound infection and meningitis; however they are rare agents for airway illnesses. Immunocompromised states, patients prone to aspiration, alcoholics, cigarette smoking and prolonged hospital stay are risk factors for invasive enterococci infection [3, 4]. Few cases of low respiratory tract infections reported are community-acquired pneumonia (CAP), ventilation- associated pneumonia (VAP), lung abscess and empyema [5-14].

Organizing pneumonia may result from nonspecific reaction to lung injury or other disease process to lung which can range from infection, drugs, inhalation injury, malignancy rheumatoid disease and many more. Our case of necrotizing organizing pneumonia by enterococcus infection has never been described in literature. In this case, we can argue that gastric decontamination with antibiotics allowed selective colonization and ultimately invasion of lung parenchyma with enterococcus. An association between the use of gastric decontamination and an increase in the incidence of enterococcus infections has been reported before [15]. Increasing importance of enterococci as a possible pathogen is necessary to solve problems of treating infections caused by these bacteria.

Our case is interesting as this old gentleman presented with non-resolving apical lung mass. This led physicians to pursue for malignancy workup while the mass continued to grow due to lack of proper diagnosis and treatment.

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Clinical Infection and Immunity is published by Elmer Press Inc.