B73-22 Stenotrophomonas Maltophilia-Associated Alveolar Hemorrhage in an Immunocompetent Patient With Tracheostomy and Ventilator-Dependence: A Case Report

Introduction Stenotrophomonas maltophilia is an aerobic, gram-negative rod common in patients that are immunocompromised or have chronic lung diseases such as cystic fibrosis. Rarely associated with hematologic malignancy, S.maltophilia may present as a fatal hemorrhagic pneumonia. We present a case of massive hemoptysis secondary to S.maltophilia pneumonia in an immunocompetent male. Case Report A 41-year-old male with limb girdle muscular dystrophy, HFrEF, and chronic hypoxic respiratory failure status post tracheostomy with ventilator dependence presented to the ED for increased oxygen requirement, dyspnea, and new in-line bloody secretions following recent tracheostomy exchange. He was admitted to the MICU necessitating bronchoscopy due to presumed pneumonia, hemoptysis, or mucus plugging. Shortly after admission, he developed elevated peak pressures with desaturation and frank bloody secretions. A difficult airway code was called due to concern for tracheostomy malfunction and desaturation to 17% despite in-line suctioning. Airway was secured via the patient’s mature tracheostomy site. Diagnostic bronchoscopy demonstrated massive hemoptysis requiring cryotherapy for clot removal from the left lower lobe, lingula, and right upper lobe, and aerosolized tranexamic acid. Following hours of bronchoscopic investigation with ongoing bleeding, CTA Chest revealed no active bronchial artery bleeding and extensive new airspace consolidations in the upper lungs with worsening ground-glass opacities. Embolization was deferred; treatment with nebulized tranexamic acid and empiric ceftriaxone was initiated. Sputum cultures later grew Stenotrophomonas maltophilia and trimethoprim-sulfamexazole therapy was initiated. Although his oxygen requirements gradually improved, he continued to have intermittent frank blood from his in-line secretions necessitating one unit PRBC transfusion for hemoglobin below 7. Repeat bedside bronchoscopy on hospital day 3 and 13 demonstrated residual clots in the left lower and right upper lobes without evidence of active hemoptysis. Discussion The incidence of S.maltophilia, a multidrug resistant organism capable of biofilm production, has increased in recent years. S.maltophilia respiratory infections confer a 28-day mortality rate up to 54% partly related to secretion of an extracellular protease responsible for tissue destruction and vascular damage. The mortality rate increases to 100% with the hemorrhagic presentation, typically seen in hematologic malignancies related to pre-existing cytotoxic alveolar damage. In ventilator-dependent patients, poor airway clearance leads to recurrent pneumonia with resultant chronic inflammation promoting interstitial remodeling and angiogenesis. This population is thus at a higher baseline risk for pneumonia-related hemoptysis. Our case demonstrates a need for vigilance and early intervention to prevent fatality in other etiologies of alveolar inflammation, such as S.maltophilia pneumonia.