A49-24 To Drain or Not to Drain? Catastrophic Bronchopulmonary Fistula After Percutaneous Lung Abscess Drainage

Abstract Introduction Lung abscess is defined as a circumscribed area of pus or necrosis in the pulmonary parenchyma caused by microbial infection. Most arise from aspiration of oral and gastric content, necrotizing pneumonias, bronchial obstruction or hematogenous spread. We present a case of lung abscess complicated by bronchopleural fistula requiring extracorporeal life support. Case A 47-year-old female with asthma/COPD overlap, polysubstance use disorder presented to the hospital with a two-month history of cough, fatigue, and weight loss with stable hemodynamics. Labs significant for leukocytosis WBC 20.6K with neutrophilic predominance, bandemia, and lactic acid 8.8. Chest x-ray demonstrated right lung mass with air fluid level. Computed Tomography (CT) showed 9.9 cm thick walled loculated fluid collection in right upper lobe (RUL). Blood cultures were negative, Urine culture showed E coli. Streptococcus pneumoniae urine antigen was positive. Antibiotics escalated from Piperacillin-Tazobactam to Meropenem. Due to lack of improvement in her symptoms, Chest CT scan was repeated six days later, showed enlarging abscess now to 12.4 cm. Upon multidisciplinary discussion, the decision was made for chest tube drainage, under CT guidance. 70 ml of foul-smelling purulent fluid was drained, cultures grew E.coli and Prevotella. A few hours later, she developed significant respiratory distress due to aspiration and was intubated. She was noted to have persistent air leak concerning for bronchopleural fistula given the recent chest tube placement. Shortly she went into refractory shock despite maximal vasopressor support and emergently cannulated for Veno-arterial Extracorporeal membrane oxygenation (ECMO) and transferred to an ECMO center. Her clinical course was complicated by evolving ARDS, spontaneous right frontal subarachnoid hemorrhage, gastrointestinal bleeding, and severe portal hypertensive gastropathy requiring multiple blood transfusions. Unfortunately, the patient passed away due to multi-organ failure. Discussion Lung abscess is treated with prompt initiation of antibiotics, often requiring a prolonged course. A small portion of cases fail antimicrobials and require drainage procedure or surgical resection. The primary indications for percutaneous drainage of lung abscess are centered around patients who fail to respond to medical therapy and those at high surgical risk. Clinicians should consider the risks of pleural contamination, empyema, and bronchopleural fistula prior to lung abscess drainage. A Case series report an incidence of persistent bronchopleural fistula of up to 8% and an overall mortality rate of 4% after CT-guided percutaneous drainage; therefore, the decision to pursue invasive intervention may require careful risk assessment and multidisciplinary input. This abstract is funded by: N/A