HYPERSENSITIVITY PNEUMONITIS PRESENTING AS SEVERE CYSTIC LUNG DISEASE FOLLOWING COVID-19 INFECTION

ABSTRACT

SESSION TITLE Dirty Jobs Occupational Lung Diseases SESSION TYPE Case Reports PRESENTED ON 10/18/2022 1115 am - 1215 pm INTRODUCTION: Hypersensitivity Pneumonitis (HP) is a group of immunologically mediated lung diseases. It develops in susceptible individuals with exposure to provoking antigens along with influence from genetic and environmental factors. There remains no standardized approach for assessing the various forms of HP and the diverse nature of the disease makes it difficult and often underdiagnosed. Cystic disease is not uncommon in HP, but the advanced cystic disease seen in our young patient was unique and likely compounded by her pregnancy as well as a previous illness with COVID-19. CASE PRESENTATION A 26-year-old female construction worker at 12 weeks gestation, with a past medical history of polysubstance abuse and previous COVID-19 infection ten months prior, presented with progressively worsening dyspnea of 9 months. She was admitted with acute hypoxic respiratory failure due to recurrent right pneumothorax requiring multiple thoracenteses and eventually chest tube placement. CT Chest demonstrated severe cystic interstitial fibrosis with emphysematous changes. Initial lung biopsy showed interstitial fibrosis as a possible sequela of COVID-19. Due to her pregnancy and medical complications, she was transferred to a transplant center where she continued to have recurrent pneumothoraces requiring video-assisted thoracoscopic surgery. Autoimmune workup, HP panel, and extended myositis panel were negative. However, a repeat lung biopsy pointed to subacute HP. Despite steroid and immunosuppressant initiation, her hospital course was complicated by cardiac arrest and brain death. She went on to become an organ donor. DISCUSSION: Diffuse cystic lung diseases are characterized by parenchymal destruction of the airway walls leading to expansion of the distal airspaces forming multi-lobular cysts. A broad differential diagnosis for this exists including infection, Langerhans histiocytosis, lymphangioleiomyomatosis, interstitial pneumonia, and HP. The first step to evaluate HP is a detailed history of potential exposures. Our patient worked in construction and was exposed to commonly demonstrated antigens used in paint, plastic, and wood manufacture. Pregnancy appears to trigger symptoms in some patients, seen in prior case reports. Our patient's symptoms began after her COVID infection. Though not clearly studied, some studies have proposed that dysregulation of COVID - 19 immune response triggers interstitial fibrosis as a long-term sequela. Early diagnosis and treatment with steroids are vital to the treatment and prevention of complications such as recurrent pneumothorax. CONCLUSIONS: Covid-19 is an emerging risk factor for the propagation of various immune-mediated diseases. Progression of disease may occur even after the infection has been cured and limited data is available regarding its relation. Early recognition and treatment can be effective life-saving measures in these patients. Reference #1 Baldi BG, Carvalho CRR, Dias OM, Marchiori E, Hochhegger B. Diffuse cystic lung diseases differential diagnosis. J Bras Pneumol. 2017;43(2)140-149. Reference #2 Densem C, Niven R, Barber P, Bishop P. Development of cryptogenic fibrosing alveolitis during pregnancy. J R Soc Med. 1998;91(11)591-593. Reference #3 Ambardar SR, Hightower SL, Huprikar NA, Chung KK, Singhal A, Collen JF. Post-COVID-19 Pulmonary Fibrosis Novel Sequelae of the Current Pandemic. J Clin Med. 2021;10(11)2452. Published 2021 Jun 1 DISCLOSURES No relevant relationships by Anastasia Brit No relevant relationships by Steven Colby No relevant relationships by Patrick Koo No relevant relationships by Vishruth Vyata No relevant relationships by Harika Yadav