Case 252

 We present a seventy seven-year-old male suffering from fever, cough, and dyspnea. He had smoked in the past and stopped smoking at present. He had enjoyed an active daily life. He had undergone aortic stent graft for abdominal aortic dissection and metallic stent for carotid artery stenosis. His COVID-19 antigen test was positive which made him introduce to our hospital for admission four days after the onset (Day 4). He received chest CT which showed mild ground glass opacity along with the marginal area of pleura and fissure (Fig.1). As least evidence of hypoxemia, he got pneumonia with Moderate Stage I COVID-19. On Day 12, fever had gone and on Day 15, he was discharged. However, Day 19, fever recurred and Day 23, antibiotics of LVFX were given for suspecting bacterial pneumonia. Day 26, he received the second CT which showed dense ground glass opacity with melon skin pattern (crazy paving appearance) (Fig. 2). Day 32, he was re-admitted to our hospital for fever at night, dyspnea and hypoxemia. Blood gas analysis under O2 2L/min inhalation revealed pH 7.47, PO2 65 mmHg, PCO2 32 mmHg. Laboratory test revealed LDH 337 IU/L, KL-6 1220 U/mL. Day 34, he received third CT which showed more dense ground glass opacity with melon skin pattern and pleural fluid (Fig.3). The respiratory symptoms did not improve following cease of his regular medicine. Further, results of other various kinds of test: β-D glucan, aspergillus antigen test, MPO-ANKA, PR3-ANKA RF factor were negative. Day 37, Broncho alveolar lavage (BAL) fluid revealed neutrophils 74.5% (40-71), lymphocytes 6.0% (19-48), eosinophils 7% (0-7), macrophages 12.5% (3.4-9.0). Day 38, he received fourth CT which showed extensive consolidation in the whole lung except the left upper lobe (Fig. 4). Steroid treatment was initiated since organizing pneumonia was suspected. Heparin was also given since D dimer was elevated to more than 80 g/mL and ultrasound showed suspicious thrombus in lower extremity veins. Day 40, respiratory condition worsened and PF ration lowered to 180mmHg, indicating to fall into acute respiratory distress syndrome. He was left under artificial respirator control. Day 51, regrettably he passed away.

What is clinical diagnosis based on clinical progress、chest CT (Fig. 4) and BAL findings (Table 1) ?

A.　Bacterial pneumonia B.　Viral pneumonia C.　Fungus pneumonia D.　Acute respiratory distress syndrome

1.　A,B

2.　B,C

3.　C,D

4.　B,D

answer

2021.12.10