Nodular pneumocystis jirovecii pneumonia complicated by air embolism during CTguided lung biopsy

1
Nodular pneumocystis jirovecii pneumonia
complicated by air embolism during CT-guided
lung biopsy
Heather Devick, MD Adam Sherwat, MD Craig
Kessler, MD Georgetown University Hospital,
Washington, DC
Abstract
Discussion
Hospital Course
History and Physical Exam
Pneumocystis jirovecii pneumonia is a well known
complication in the AIDS population but also
occurs in other immunosuppressed patients. This
case presents a patient with T-cell lymphoma on
chemotherapy and dexamethasone admitted with
fevers and shortness of breath. He is diagnosed
with Pneumocystis jirovecii pneumonia but has no
improvement on pentamidine and steroids. To
further evaluate his lung lesions, CT-guided lung
biopsy was performed. The procedure was
complicated by air embolism causing the patient
to go into cardiac arrest. Air embolism is a
known but rare and potentially fatal complication
of lung needle biopsy. The occurrence has
increased over the past several years with the
progression of radiographic technology.
HPI Mr. AJ is a 64 year old male with a history
of angiolymphoblastic T-cell Lymphoma (receiving
Gemcitabine) admitted with a chief complaint of
fevers/chills. The fever along with a rash on
the patients face and arms began during a blood
transfusion several days prior to admission. The
transfusion was stopped, and the patient was
monitored for any further complications from the
transfusion. Upon follow-up in clinic several
days later he remained febrile. He also
complained of dyspnea on exertion, a productive
cough of clear sputum, and increasing weakness.
In the ER, he was febrile to 38 degrees Celsius.
Chest X-ray showed a new right perihilar
infiltrate. Past Medical History 1.
Angiolymphoblastic T-cell Lymphoma
2. Hyperlipidemia
3. Oral candidiasis
4. Oral
ulcers Family History Mother died of MI at age
86. Father died of CVA. Social History No
tobacco use. Social alcohol use though none
currently. Immigrated to US in 1969 from the
Ukraine. Negative PPD 2 weeks prior to
admission. Allergies Sulfites Medications
Dexamethasone 2mg PO BID, Acyclovir 400mg PO BID,
Fluconazole 200mg PO Daily, Allopurinol 300mg PO
Daily, Gemcitabine (Cycle 1) Physical Exam
T38 degrees Celsius Blood Pressure120/72
Heart Rate105 Respiratory Rate18 (oxygen
saturation of 95 on room air) General no
distress, sleeping/easily arousable HEENT EOMI,
dry mucus membranes, oral lesions Lungs clear to
auscultation bilaterally, decreased breath sounds
at bases Cardiovascular tachycardic, normal
S1/S2, no murmurs Abdomen normal bowel sounds,
soft, nontender, no organomegaly Extremities no
edema, 2 pedal pulses Skin blanching
erythematous maculopapular rash on
face/chest/abdomen Neurologic alert and
oriented, no focal deficits
The role of PJP prophylaxis in non-HIV patients
and the occurrence, treatment, and prevention of
air embolism are several topics introduced by
this case. It is well known that prophylaxis in
HIV positive patients begins when the CD4 count
is below 200, but not as clearly defined for
other immunosuppressed patients. Patients
receiving immunosuppressive medications such as
steroids for a prolonged period or those with an
underlying immunodeficiency should receive
prophylaxis. A retrospective study showed an
equivalent of 16mg prednisone over 8 weeks
significantly increased the risk of PJP (4).
This has also been seen in other studies where
cancer and connective tissue disease patients
were treated with steroids (1). The reported
incidence of air embolism as a complication of
lung needle biopsy is 0.07 (3). A study of 9783
biopsies showed pneumothorax as a complication in
35 and severe complications in 0.75 including
air embolism in 0.061 (5). Treatment includes
100 oxygen. Hyperbaric oxygen has also been
shown to improve outcome (6). Positioning is
controversial but the current recommendation is
to have the patient supine (7). Prevention
includes avoiding biopsy of bullous, cavitary,
or cystic lesions occlusion of the needle/stylet
at all times having the patient refrain from
valsalva maneuvers using CT guidance and
selecting a site with the least amount of lung
parenchyma (3).
The patient was admitted to the medicine service
with pneumonia and empirically started on zosyn
and vancomycin. The night of admission he
developed hypoxia and increasing respiratory
distress. CT Thorax showed multifocal areas of
mass-like consolidation and ground glass nodules
concerning for fungal infection, so ambisome was
started. On his third day of admission he had
no improvement in clinical status and was
transferred to the Medical ICU for a
bronchoscopy/respiratory monitoring.
Post-bronchoscopy the patient went into
respiratory distress requiring intubation and
became hypotensive requiring the use of pressors.
His leukocytosis continued to worsen with a
white blood cell count now at 17.4. The
bronchoalveolar lavage was positive for
Pneumocystis jirovecii pneumonia, and Bactrim was
started the patient was already on stress dose
steroids. Bactrim was changed to IV pentamidine
due to a drug rash. Ambisome was discontinued
after 7 days of negative fungal
cultures. Despite pentamidine and steroids, Mr.
AJs respiratory status failed to improve, and he
remained febrile. A repeat CT Thorax showed new
cavitary lesions in the lower lobes, an increase
in the ground glass opacities, and cavitation of
the areas of consolidation. To further evaluate
his pulmonary disease, a CT-guided biopsy of a
cavitary lesion was done. During the
repeat CT-guided lung biopsy, the patient went
into cardiac arrest (pulseless ventricular
tachycardia). Chest compressions were performed,
and the patient was resuscitated to sinus
tachycardia. Imaging showed air embolism in the
aorta and coronary arteries. There was also a
left pneumothorax a chest tube was
placed. Lung biopsy showed necrotic
debris. Mr. AJs respiratory status failed to
improve. Ambisome was restarted, but there
remained no improvement in clinical status. Care
was eventually withdrawn per the patients wishes
of not being on prolonged life support.
Introduction
Pneumocystis jirovecii pneumonia (PJP) is a
well known opportunistic infection prevalent in
the AIDS population but also occurs in other
immunosuppressed populations. This case presents
a patient with T-cell lymphoma receiving
chemotherapy and steroids that is diagnosed with
nodular PJP. The mortality rate in patients with
PJP in the absence of AIDS is 30-60 with an
increased risk of death among patients with
cancer. Typical radiologic findings are
bilateral perihilar infiltrates solitary or
multiple nodules are less common (1). Predictors
of death include increased age, tachypnea, high
APACHE II score, mechanical ventilation,
vasopressor use, low arterial oxygen pH, and
pneumothorax. Mechanical ventilation has been
found to be an independent predictor of death
(2). In this case, despite appropriate
treatment for PJP the patient worsened. To
further evaluate the lung nodules/cavitations on
CT, CT-guided biopsy was pursued an increasingly
common way to further evaluate pulmonary nodules
is by needle biopsy. Despite radiographic
advances, this method is not without risks. A
rare yet potentially fatal complication is a
systemic air embolism. There are three
mechanisms by which air can enter the vasculature
during a needle lung biopsy 1. By removing
the stylet while the needle is in the pulmonary
vein, there can be a direct
communication between the atmosphere and vessel.
2. A bronchovenous fistula could be formed
upon the passage of the needle through the lung
parenchyma. 3. Air could also traverse the
pulmonary microvasculature without a fistula.
Air entering into the pulmonary vein then
travels to the left atrium, the left ventricle,
and then reaches the systemic circulation(3).
Figure 2. CT Thorax showing internal cavitation
of multiple bilateral masslike areas of
consolidation, new cavitary lesions in the lower
lobes, and an increase in ground glass opacities.
Conclusions
PJP is not exclusive to AIDS patients. Non-AIDS
patients have a higher mortality. Patients
receiving immunosuppressive medications such as
steroids or those with underlying
immunodeficiencies should receive PJP
prophylaxis. Air embolism is a rare but
potentially fatal complication of lung biopsy.
C
D
Initial Labs/Imaging
References

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A
B
Figure 3. (C-D). C) CT Thorax after cardiac
arrest showing air in coronary artery. D) CT
Thorax showing air in aorta.
Sodium125 Potassium4 Chloride88 Bicarbonate29
BUN16 Creatinine0.8 Glucose138
WBC6.2 Hemoglobin7.5 Hematocrit21.7 Platelets1
89 Blood Cultures were Negative
Figure 1. (A-B). A) Chest x-ray showing right
perihilar infiltrates. B) CT Thorax with
multifocal areas of mass-like consolidation with
adjacent ground glass nodules.