Though community acquired pneumonia (CAP) remains a common source of respiratory failure, recent changes to disease incidence have given increased concern to other pathologies, notably COVID-19 and e-cigarette or vaping associated lung injury (EVALI). When all other diagnoses are exhausted, there is a turn to consideration of cryptogenic organizing pneumonia (COP), an idiopathic disease. We describe an unexpected finding in a young, otherwise healthy woman who was initially treated for presumed COP when all other diagnoses were ruled out. Case report: A 49-year-old female with no past medical history presented with dyspnea, cough, and progressive weakness for two weeks. Social history was significant for daily vaping. Vitals revealed a fever of 103.3°F, heart rate of 108 bpm, and respiratory rate of 18 with an oxygen saturation of 89% on room air. Physical exam was notable for decreased breath sounds at the lung bases and poor inspiratory effort. CT angiogram was negative for pulmonary embolism but demonstrated bilateral multifocal consolidates and ground-glass opacities concerning for COVID-19 or pneumocystis pneumonia. Labs showed elevated c-reactive protein, d-dimer, and liver function tests. Testing was negative for HIV and COVID-19, at which point isolation precautions were discontinued. Given that other diagnoses were likely ruled out and alternative explanations for her findings were inconclusive, treatment was initiated and directed towards COP. Diagnostic bronchoscopy was performed and complicated by blood clots in the posterior subsegmental lobes, requiring intubation and ICU transfer, by which time bronchoalveolar lavage (BAL) returned positive for COVID-19. With concern for COP due to COVID, treatment was shifted towards management of both disease states with initiation of solumedrol and remdesivir per hospital-specific protocol at the time. Her condition improved with treatment, allowing for extubation and discharge home on low flow supplemental oxygen. Discussion: A patient who presents with nonspecific respiratory complaints without COVID-19 exposure, multiple negative tests, and bloodwork inconsistent with typical infection can pose a significant challenge to healthcare workers. This case was initially treated as COP with differentials including pneumocystis or eosinophilic pneumonia, CAP, and EVALI. After finding COVID-19 in the BAL of a low suspicion case with multiple negative nasal swabs, it is clear that the exclusion of this disease was premature despite guideline-based testing. It also proposes the possibility of developing COP from COVID. This infection must continue to be considered in the setting of acute hypoxemic respiratory failure in spite of local disease patterns and negative PCR tests.
A Complex Case of Acute Hypoxemic Respiratory Failure in 2020