An 82-year-old woman, non-smoker and with no morbid history, was admitted for chronic diarrhea syndrome in 2012.
An extensive study failed to demonstrate its etiology and CT scan of the abdomen and pelvis revealed and cystitis compatible with gastroenteritis, which resolved after one month of diet and ciprofloxacin.
Prior to discharge, dyspnea, desaturation, tachypnea, tachycardia, fever of 37.5°, leukocytosis of 38,100/μL, C-reactive protein (CRP) ratio of 99.6 mg/dL
Pulmonary thromboembolism (PTE) was ruled out; however, CT angiography and chest X-ray showed multilobar pneumonia in the right upper and left lower lobe with right pleural effusion (PPE).
The patient was initially treated with piperacillin-tazodone.
Blood cultures, sputum smears, respiratory viruses, and urinary antigens for pneumococcus and legionella were negative.
DP study showed polymorphonuclear exudate, with normal adenosine deaminase (ADA) values and pH.
He required non-invasive mechanical ventilation (NIV) and achieved high levels of inappropriate parameters. On the tenth day, the spectrum was extended to imipenem and vancomycin.
Fiberoptic bronchoscopy was performed, macroscopically normal, and bronchoalveolar lavage (BAL) was negative (bacilloscopies, PCR for Mycobacterium tuberculosis, bacteriological culture, culture of Koch and bacteriological culture).
Transbronchial biopsy reported "nonspecific findings".
Rheumatoid factor (RF), antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA) and antigenemia for cytomegalovirus (CMV) were negative.
After a partial improvement of 4 days, the fever recurred and she presented severe respiratory deterioration, so bacterial superinfection was diagnosed and colistin was indicated without response.
Due to the clinical deterioration, it was decided to perform lung biopsy due to stenosis which revealed diffuse alveolar damage and findings consistent with COP.
Methylprednisolone (500 mg) was initiated, followed by prednisone 1 mg/kg/day. A favorable response was observed within 7 days, with discontinuation of NIV and normalization of CRP dementia ratio.
A week later, progressing in good conditions, he died suddenly without proven cause.
