Pseudomembranous Obstructive Tracheobronchitis Caused By Methicillin-Resistant Staphylococcus Aureus In A Patient With Non-Small Cell Lung Cancer

A. Gupta , S. Faiz , L. Bashoura

Author address: 

University of Texas Health, Houston, TX, MD Anderson Cancer Center, Houston, TX

Abstract: 

INTRODUCTION: Pseudomembranous tracheobronchitis has been recognized in immunocompromised hosts including hematologic malignancies, heart transplant recipients and AIDS. It is usually associated with the Aspergillus species. We report a case of pseudomembranous tracheobronchitis secondary to methicillin-resistant Staphylococcus aureus (MRSA) in a patient undergoing chemoradiation for non-small cell lung cancer (NSCLC). CASE PRESENTATION: A 65 y.o male with a past history of tonsillar cancer underwent external beam radiation therapy causing osteoradionecrosis of the mandible. This required subsequent laryngectomy and tracheostomy. In 2008, patient was diagnosed with stage IIIA NSCLC and underwent chemotherapy with paclitaxel, carboplatin and erlotinib. Patient was admitted to the hospital due to a four week history of cough with blood tinged sputum. White blood cell count was 2,400/mm with 82% neutrophils, 5% lymphocytes and 13% 3 monocytes. Chest X-ray revealed coarse interstitial markings over the right lung. Chest CT scan did not reveal any lesion to explain the hemoptysis. Flexible bronchoscopy revealed extensive mucosal inflammation with bloody mucous plugs and pseudomembranes overlying the trachea-bronchial mucosa. Mucous plugs and pseudomembranes were removed with suctioning and the airways were cleared. Patient was started on vancomycin and piperacillin-tazobactam until the cultures were pending. Final cultures revealed MRSA from the mucous plugs and repeat sputum specimens. Viral cultures were negative. After initiating vancomycin, there was resolution of fever, cough and hemoptysis. Patient was discharged to his home after completing seven days of intravenous vancomycin. DISCUSSION: Our patient’s presentation is consistent with pseudomembranous obstructive tracheobronchitis due to the finding of membrane overlying the mucosa with extensive inflammation of the tracheobroncial tree. This case is unique since the pseudomembranous tracheobronchitis was associated with MRSA, unlike the majority of cases where Aspergillus is identified in cultures. In adults, pseudomembranous tracheobronchitis is a rare occurrence and has been recognized in severely immunocompromised patients with hematological malignancy or in mechanically ventilated patients. The disease can vary from relatively mild tracheobronchitis with cough, fever, dyspnea, and chest pain, to hemoptysis with excess mucus production and ulcerative tracheobronchitis. Usually associated with Aspergillus, pseudomembranous tracheobronchitis has been reported with MRSA in association with a previous infection with influenza and with Bacillus cereus. CONCLUSION: Along with Aspergillus, Staphylococcus aureus must be considered in the differential diagnosis for causes of pseudomembranous tracheobronchitis. The diagnosis is made on the basis of characteristic bronchoscopic appearance and is confirmed upon microscopic examination of material obtained on bronchoscopy.
2011

abstract No: 

D24

Full conference title: 

American Thoracic Society
    • ATS 2011