C42-06 Beyond Eosinophilia: Expanding the Spectrum of Daptomycin-induced Lung Toxicity

Abstract Introduction Daptomycin is a lipopeptide antibiotic widely used in the treatment of serious Gram-positive infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA). While generally well tolerated, rare but serious adverse effects have been reported. One of the most concerning is daptomycin-induced pulmonary toxicity and eosinophilic pneumonia leading to hypoxic respiratory failure. Daptomycin induced eosinophilic pneumonia is typically characterized by fever, dyspnea, hypoxia, radiographic evidence of multiple bilateral infiltrates and eosinophilia on BAL. Description We present an 88 year old male with history of atrial fibrillation on anticoagulation, chronic kidney disease stage III with solitary left kidney, ESBL bacteremia and chronic right foot osteomyelitis who presented with shortness of breath , fever and chills. The patient had completed 3 of the 4 weeks course of IV daptomycin recommended outpatient for right foot osteomyelitis. In the ED, patient was hypoxic requiring BiPAP and was admitted to medical floor. CT chest revealed significant bilateral infiltrates. Rapid progression of severe hypoxic respiratory failure requiring 100% Fio2 led to patient being intubated and started on mechanical ventilation Infectious work-up including lower respiratory cultures as well as legionella and streptococcus pneumoniae was negative. The patient received two doses of steroids prior to underdoing diagnostic Bronchoscopy. Peripheral blood eosinophilia was seen although BAL samples did not show significant eosinophilia more than 25%. Bronchoalveolar lavage cultures were negative without any evidence of Dah noted on bronchoscopy. Within a few days of stopping Daptomycin and high dose steroid treatment with IV methyl prednisone 125 every 6 hours, marked improvement in oxygenation and respiratory mechanics was observed. A repeat CT chest performed showed complete resolution of the bilateral pulmonary infiltrates and patient underwent successful ventilator liberation. Discussion In this case marked clinical improvement in acute lung injury, oxygenation and rapid resolution of imaging findings suggestive of daptomycin induced lung injury reinforced the suspected diagnosis of acute lung injury secondary to daptomycin. The initiation of steroids prior to bronchoscopy can decrease the diagnostic yield for BAL eosinophilia. The absence of one diagnostic finding of BAL eosinophilia should not preclude early recognition and treatment of Daptomycin-induced lung injury. Early recognition and awareness of this rare but serious pulmonary toxicity can lead to improved outcomes in rapidly progressive respiratory failure in daptomycin induced lung injury. This abstract is funded by: None