Blog | Wednesday, May 1, 2013

Medical sleuths: Help wanted

Laura N. is a friend. A relative of hers is in a bad way: critically sick, with different specialists thinking along different lines both in terms of what's going on with the patient and the best way(s) to help.

Please offer your help or questions in the comments or contact me if you'd like more information.

The patient is male, in his 60s. He was diagnosed some time ago with Non-Hodgkin's lymphoma. The lymphoma has been successfully treated, but six or so years after diagnosis, complications ensued: respiratory distress and a diagnosis of something called "bronchiolitis obliterans/organizing pneumonia (known as "BOOP" [really], but now often referred to as "COP," i.e. cryptogenic organizing pneumonia).

Next the patient was found to have cryptococcal pneumonia (a type of fungus that can infect immune compromised individuals).

After treatment for that, the patient was found to be infected with an invasive, hard to treat and multi-drug resistant type of bacteria called Pseudomonas aeruginosa. Since the bacteria were resistant to nearly all antibiotics, the doctors used an old antibiotic that's fallen out of favor due to its toxic effect on kidneys known as colistin.

Astonishingly, given the patient's precarious respiratory status (and protracted hospital course), he started to undergo daily bronchoscopies to assure clearance of both the pathogen and the copious amounts of mucous produced. The doctors then added tobramycin washes (another antibiotic) to his lungs via the daily bronchoscopies.

The thing that's stumping the doctors is the bronchorrea, the copious amount of mucous production from the lungs, given that the patient has had nearly all of his microbiome eradicated.

Again: your ideas on what's causing his profound respiratory secretions and poor ventilation (high pCO2), in addition to ideas for further treatment, are very welcome.

Here's a four-liner to help focus the issues: _____ is a 60ish year-old male with non-Hodgkin's lymphoma since 2006 s/p CFR treatment complicated by BOOP, subsequent cryptococcal pneumonia, prolonged hospitalization (now > 8 months inpatient) with multiple intubations now growing MDR P. aeruginosa in blood and BAL washings. On colistin IV and tobramycin pulmonary washings as latest salvage measure, unclear if achieving adequate serum levels. Also on an experimental tyrosine kinase inhibitor called "Ibrutinib" as part of CLL protocol. Prolific bronchorrea, severe malnourishment and deconditioning.

Let us know your ideas or what other information you'd like.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.