HYPERSENSITIVITY PNEUMONITIS IN THE BACKGROUND OF SUSPICION FOR SEVERE PNEUMONIA AND HISTORY OF HYPERTENSIVE URGENCY;THE SIGNIFICANCE OF MEDICAL HISTORY AND EARLY INTERVENTION

ABSTRACT

CASE A 61-year-old male with self-reported coronary artery disease (CAD), Hypertension, and bipolar disorder who presented to the Emergency Room with dyspnea. STAT chest CT angiography (CTA) was negative for pulmonary embolism but it demonstrated scattered patchy ill-defined bilateral ground-glass opacities concerning for possible atypical viral pneumonia. Basic work-up showed elevated WBC count and lactic acid. He was started on supportive management and empirical Ceftriaxone and Azithromycin. While on the hospital floor, he started to have sinus- tachycardia and hypoxia necessitating escalation in supplemental oxygen delivery modality. He was later transferred to the ICU. Patient's hypoxic respiratory failure was suspected to be an acute process strongly including COVID-19 pneumonia. Acute bacterial insult was also considered as the WBC count was elevated and this consideration discouraged against starting immunosuppressive regimen targeted against possible COVID-19 pneumonia. A repeat CT scan of the chest was ordered to better highlight the pulmonary findings. The study could not be completed as the patient was unable to lie flat and was developing hypoxia. The diastolic blood pressure (DBP) was noted be elevated and STAT chest xray showed flash pulmonary edema. The patient was started on IV diuretics and potent IV antihypertensive medications. He had not seen a physician for a long time and the medical charts were deficient. The patient soon disclosed that he had recently used synthetic form of inhaled cannabinoids and that he had a similar episode after using synthetic inhaled cannabinoids one year prior. In the meantime, the patient tested negative the second time for COVID-19 infection. Taking these new developments into consideration, the suspicion for an infective pulmonary process did not remain very strong. He was started on IV steroids to address possible hypersensitivity pneumonitis which resulted in prompt and drastic improvement in his respiratory status. IMPACT/DISCUSSION: The patient's unknown COVID-19 vaccination status, pulmonary imaging findings, and the sudden respiratory decompensation very strongly supported possible COVID-19 pneumonia. Acute bacterial pneumonia was also on the differential diagnoses list. The patient's active bipolar disorder made history-taking quite challenging. Since the treatment modalities targeted against the possible etiology of his respiratory failure varied greatly, the need for a clinical diagnosis was imperative. CONCLUSION: Medical history-taking is the backbone of medical practice. It has the highest yield when it comes to patient management. Our patient presented with a spectrum that would be applicable to multiple pathological processes but at the end it was a case of hypersensitivity pneumonitis to a known allergen that was complicated by the presence of hypertensive urgency. IV steroid initiation made significant improvement in the patient's respiratory status as evidenced by the promptly decreasing supplemental oxygen need.