A 40-Year-Old With Prior Stem Cell Transplant for Chronic Myeloid Leukemia Presents With Dyspnea and Respiratory Failure

Abstract

A 40-year-old man with chronic myeloid leukemia presented to the hospital with recurrent dyspnea and hypoxemic respiratory failure. He presented from his outpatient transplant infectious diseases appointment with dyspnea, cough, worsening hypoxemia, acute kidney injury, and somnolence after discharge from the hospital 2 weeks prior with a similar presentation. During the previous hospital stay, he underwent bronchoscopy and alveolar lavage with negative infectious workup. He was prescribed caspofungin, amphotericin, and continued posaconazole for prior probable invasive fungal infection (elevated blood BD-glucan and pulmonary nodules). Antibiotics included previous meropenem for esophageal nocardiosis, cefepime and azithromycin during admission, and now ceftriaxone for nocardiosis in the outpatient setting for convenience of home infusion. He was prescribed diuretics for presumed volume overload. Despite home diuretics, antimicrobials, and supplemental oxygen, he re-presented with worsening symptoms.

Figure 1

A, Portable semi-recumbent AP chest radiograph on admission. B, Chest CT showing bilateral lower-lobe ground-glass.

Figure 2

Lung biopsy. (A) Hematoxylin and eosin stain showing intra-alveolar exudates (magnification: 4×). (B) Periodic acid-Schiff (PAS) stain showing positive globules (arrow) (magnification: 20×).

Figure 3

Lung lavage performed at the bedside showing pink proteinaceous return in setting of thrombocytopenia.