A Rare Cause of Acute Respiratory Distress Syndrome (ARDS) in Young Patients

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Introduction Trimethoprim-Sulfamethoxazole (TMP-SMX) is an antibiotic commonly used to treat different infections, including prophylaxis in immunocompromised individuals. It has numerous side effects; in this case we describe a rare pulmonary complication from chronic use of TMP-SMX. Description A 17-year-old female presented to the Emergency Department with a three-day history of fever (temperature max of 39.4C), exertional dyspnea, body aches and hypoxia (SpO2 70-80% on home oximeter). Her home medications included TMP-SMX prescribed one month prior to presentation for acne vulgaris and escitalopram. She denied any allergies, sick contacts, or travel. On presentation, the patient was hypoxic on room air (SpO2 80- 90%), tachypneic (30-40 breaths/min), and tachycardic (113 beats/min). Exam revealed bilateral decreased breath sounds and conversational dyspnea. Computed Tomography (CT) Angiography of the Chest revealed diffuse multinodular airspace opacities bilaterally with no pulmonary embolism (Image-left). Labs revealed mild leukopenia (3.5 bil/L), anemia (10.3 g/dL), thrombocytopenia (146 bil/L), and mildly elevated procalcitonin (0.4 ng/mL). Extensive infectious and autoimmune workup were unremarkable. The patient was transferred to the Incentive Care Unit on heated high flow oxygen and was started on empiric antibiotics. Her respiratory failure worsened and she was subsequently intubated for severe ARDS. Bronchoalveolar lavage was completed, revealing neutorphilic alveolitis without any infection. Subsequently, systemic corticosteroids were initiated. She slowly improved and was extubated on ventilator day 5. She was discharged on 2 liters of oxygen with a steroid taper. Genetic testing revealed the presence of HLA-B0702 and TMP-SMX induced ARDS was considered the most likely diagnosis. She followed up in pulmonary clinic after two months when repeat CT Chest revealed diffuse reticulonodular opacities throughout the lungs, worst at the lung bases (Image-right). She has been weaned off oxygen and is attending college. Discussion TMP-SMX associated ARDS has been reported infrequently in children and young adults, and the pathophysiology remains unclear. These patients often require invasive respiratory support, with one study showing 80% of patients requiring extracorporeal membrane oxygenation (ECMO) for an extended duration and a 40% in-hospital mortality. Genetic testing disclosed the presence of HLA-B0702 in our patient. Prior studies have shown the presence of HLA-B0702 and HLA-C0702 in 100% of subjects with respiratory failure due to TMP-SMX, suggesting that the presence of these genes are necessary to develop this condition. Future studies should explore this relationship and comment on whether clinicians should test for the presence of HLA genes prior to starting young patients on TMP-SMX to prevent this complication.

Volume

209

Issue

Suppl

First Page

A1141

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A1141

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