A50-33 To the Brink and Back: A Course of Severe Necrotizing Pneumonia

Abstract Introduction Necrotizing pneumonia (NP) is a rare, but a life-threatening complication of community acquired pneumonia (CAP). Early diagnosis is crucial, as delayed diagnosis is associated with increased mortality and morbidity. We present a rare case of NP, highlighting the challenges we faced while managing this complication. Case A 50-year-old Caucasian female with past medical history of alcohol use disorder and COPD presented via air transfer for acute hypoxic respiratory failure. On arrival, she was on Airvo - 50L/min with 60% FiO2. Her respiratory status rapidly deteriorated necessitating intubation and mechanical ventilation. CT chest with contrast demonstrated centrilobular emphysema with mixed alveolar and interstitial opacities. Blood cultures (2/2 sets) grew streptococcus pneumoniae. Despite appropriate treatment, she continued to be severely hypoxic with PaO2/FiO2 ratio of 119. Diagnostic bronchoscopy revealed thick, obstructing mucous in the right lower lobe and in the bilateral lower lung fields. Following bronchoscopy, she continued to have persistent fevers up to 104 F. A repeat CT scan revealed necrotizing pneumonia with diffuse septal wall thickening and a new 10 cm cavity centered in the right lower lobe (Image). BAL cultures subsequently grew E.coli sensitive to carbapenems. Despite the antibiotic adjustment, she remained febrile and hypoxic, requiring tracheostomy and PEG tube placement. Her course was complicated by the development of right hydropneumothorax requiring chest tube placement. Throughout this, she continued to experience fevers up to 102 F. A thorough evaluation for an alternative infectious source was negative, and her persistent fevers were presumed to be secondary to cytokine storm from the necrotic lung mass. Surgery was deferred due to severe malnutrition. Over the period of next 25 days, she demonstrated a meaningful recovery and was later discharged without requiring any additional care needs. Discussion NP is a severe complication of CAP, characterized by liquefaction of lung tissue, leading to cavitation. It is a rare manifestation of bacterial lung infections, with a reported prevalence as low as 1% and a mortality as high as 45%. Our case underscores the importance of prompt diagnosis and also reinforces the potential for polymicrobial involvement. Recognizing risk factors and early indicators of worsening pneumonia can guide timely diagnosis and help reduce mortality. Our case also reinforces the fact that diagnosis and management of NP remain challenging, due to lack of consensus definition or a criterion for diagnosing NP. More clinical trials are needed to establish standardized guidelines for the diagnosis and management of NP. This abstract is funded by: none