D110-14 A Silent Collapse: Asymptomatic Patient With Fulminant Lung Necrosis

Abstract Introduction Pulmonary vein obstruction (PVO) is a rare condition with diverse etiologies, from congenital anomalies to malignant growth (1). Its true incidence remains unknown as it is primarily documented through case reports. Typically, patients present with shortness of breath and hypoxia. Management is individualized as the inciting event varies. Sequalae from pulmonary vein obstruction typically results in pulmonary edema, pulmonary infarction, and right ventricular failure. Development of bronchopleural fistulas(BPF) secondary to PVO as the inciting factor is a rare understudied pathologic event. We present a case in which a patient presents with PVO leading to BPF in the setting of metastatic renal cell carcinoma(RCC) who initially had no respiratory complaints. Case Discussion A 56-year-old female presented with right lower quadrant pain, nausea, and hematuria. Computed tomography (CT) imaging revealed a 6.7 cm right renal mass consistent with RCC and a left hilar lung mass. Respective biopsies confirmed metastatic clear cell RCC. She began treatment with cabozantinib and nivolumab. Six months after initial diagnosis, she was admitted for fever and diarrhea. CT imaging showed her left lung upper lobe mass obstructing the L pulmonary vein, resulting in fulminant necrosis of the lung. She was then readmitted 1 week later for weakness, and a CT chest was done at this time, demonstrating the development of a bronchopleural fistula, causing a hydropneumothorax. Despite these findings she had no respiratory complaints. Given the extensive necrosis and poor functional status due to metastatic disease, treatment options were limited. Initial management discussions focused on palliative strategies, including chest tube placement or endobronchial one-way valve insertion, however as she had no respiratory complaints, there was lack of expected benefit and no intervention was done. She was readmitted two months later with her first instance of cough and putrid sputum. At this time, management discussions focused on interventions that could provide her clinical improvement and it was determined that a one-way right mainstem bronchial stent would benefit her in isolating her left sided necrotic lung space from spreading further infection to her healthy right lung. Discussion This case illustrates the rare development of a bronchopleural fistula secondary to pulmonary vein obstruction and fulminant necrosis, all stemming from metastatic RCC. Management for this patient was complex due to multiple factors and required extensive multi-disciplinary conversations. Highlighting the importance of individualized approaches for patients with BPF and taking a collaborative approach to ensure best patient outcomes. This abstract is funded by: none