ABSTRACT
Case Report 63-year-old man with history of myelofibrosis, s/p allogeneic stem cell transplant in 2018, off immunosuppression for 3 months, who presented with 5 weeks of intermittent fevers up to 102.7, malaise, productive cough, and dyspnea, with hypoxia on admission, requiring up to 5L O2. Labs showed WBC 10.8, 53% PMNs, CRP 12.9 mg/dL, ESR >80, ferritin 2563, and Na 130. CTA chest showed patchy groundglass opacities and tree-in-bud nodularity;repeat CT five days later due to ongoing fevers despite cefepime and doxycycline showed worsened diffuse GGO in the bilateral upper lobes and RML. Echo revealed newly reduced EF 35-40% with global hypokinesis. Cardiac MRI showed myocardial edema and transmural enhancement, suggestive of myocarditis. Infectious workup was unrevealing, including blood and sputum cultures, respiratory viral panel, CMV and EBV DNA PCR, fungal serologies, Q-fever, Bartonella, tickborne serologies, HIV, T-spot, and Legionella. He had two negative COVID-19 tests (unknown type) prior to admission, and two negative NP PCR tests and a negative SARS-CoV-2 antibody test in-house. Late in his course, transbronchial biopsy showed mild nonspecific inflammation with negative stains and cultures. He defervesced, and was discharged on room air after 11 days. His acute hypoxemic respiratory failure was presumed to be due to viral pneumonia and myocarditis. In an allogeneic SCT recipient with respiratory symptoms, various infectious and noninfectious etiologies (GVHD, autoimmune, drug toxicity, etc.) should be considered. Bronchoscopy can provide a more definitive etiology, and was delayed in this case due to some concern for COVID-19 despite multiple negative tests. (Figure Presented).