Pulmonary artery pseudoaneurysms and necrotizing pneumonia

Case contributed by Albina Polianskaia
Diagnosis certain

Presentation

Fever, dyspnea, and cough with brownish sputum in a patient with poorly controlled type 1 diabetes mellitus and a history of cannabis and alcohol abuse. Pulmonary embolism needs to be ruled out.

Patient Data

Age: 40 years
Gender: Female

Irregularities of the lobar arteries in both lower lobes, with aneurysmal dilatations that correspond to mycotic pseudoaneurysms. Multiple bilateral consolidations, some with cavitations.

Patchy ground-glass opacities and interlobular septal thickening, mainly in the upper lobes, along with bilateral pleural effusions, possibly due to associated heart failure.

No pulmonary embolism detected.

Case Discussion

The patient was admitted with community-acquired necrotizing pneumonia caused by S. aureus, Haemophilus influenzae, S. agalactiae, and the influenza A virus. Subsequently, the pneumonia was complicated by a pleural fistula, resulting in ventilation difficulty and associated hypoxemia unresponsive to prone positioning. The severe respiratory failure necessitated support with veno-venous extracorporeal membrane oxygenation (VV-ECMO) for one month.

During the first week of hospitalization, the patient experienced an episode of hemoptysis due to the rupture of a pulmonary pseudoaneurysm, leading to cardiac arrest. This required cardiopulmonary resuscitation and intubation, with subsequent good recovery. Unfortunately, the patient died after another episode of massive hemoptysis four weeks later.

Pulmonary artery pseudoaneurysms are uncommon but crucial to identify due to their associated morbidity. Unlike true aneurysms, pseudoaneurysms lack involvement of all layers of the arterial wall, making them particularly prone to rupture and subsequent massive hemoptysis. Pulmonary artery pseudoaneurysms can occur secondary to chest trauma, vasculitis, iatrogenic injury, connective tissue disease or infection, like in our case.

 Case courtesy of Dra Laura Cerón Nasarre

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