Abstract Bronchiolitis Obliterans Syndrome is a noninfectious complication that can occur in patients having undergone lung transplantation. This is unusual case of BOS presenting as pneumothorax and pneumomediastinum in a lung transplant patient. 69 year old male with alpha 1 antitrypsin deficiency requiring bilateral lung transplant, acute on chronic allograft rejection improving with steroids presented with progressive shortness of breath and chest pain with associated dyspnea on exertion. Denied fever, chills, cough, sputum production. On admission, patient was noted to be tachypneic, tachycardic & was requiring 2 L O2. His laboratory investigations revealed hemoglobin/hematocrit of 11.0/33.3, hypokalemia of 2.9, elevated renal indices of BUN/Creatinine of 18/1.5, BNP of 694, Troponin of 0.129. CTA Chest was done which showed multiple small nonobstrcting intraluminal thrombi of the bilateral segmental and subsegmental pulmonary arteries, extensive pneumomediastinum & pneumopericardium with foci of subpleural air in right lung, scattered bilateral ground glass opacities. IV heparin infusion was started and switched to therapeutic dose enoxaparin the next day. Tacrolimus, Mycophenolate & Prednisone continued. Repeat CXR showed improvement in pneumomediastinum with new right lung apex opacity. Repeat CT Chest showed right apical hemothorax measuring 11.8 x 5.5 x 9.2 cm with active bleeding. Anticoagulation discontinued. Interventional Radiology consulted and patient underwent embolization of branch of right internal thoracic artery & accessory branch of thyrocervical trunk. Patient was intubated due to increased work of breathing after the procedure & remained on mechanical ventilation. Thoracic Surgery consulted and patient underwent VATS for hemothorax evacuation & chest tube placed. Patient able to be extubated to nasal cannula with persistent dyspnea on exertion. Palliative care consulted and decision made to discharge patient home with hospice after removal of chest tube. Air-leak syndromes are uncommon complications of BOS, including pneumothoraces and pneumomediastinum. Bronchiolitis Obliterans leads to obliteration of small airways and causes increased airway resistance which may contribute to development of pneumothorax. Mechanism of pneumomediastinum is thought to be due to the Macklin effect: spontaneous alveolar rupture causes free air to travel along bronchovascular sheaths into mediastinum. Management is usually conservative if disease process limited to pneumomediastinum but patients may require tube thoracostomy in case pneumothorax is present. Thoracic air-leak syndromes such as pneumomediastinum, pneumothoraces in the setting of BOS have been shown to be poor prognostic indicators in transplant patients. This abstract is funded by: None
Mahmood et al. (Fri,) studied this question.