BRONCHOPLEURAL FISTULA COMPLICATION OF INTRAPLEURAL TPA/DORNASE IN PRESENCE OF LUNG ABSCESS

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: A short course intrapleural instillation of tissue plasminogen activator (tPA) and recombinant human deoxyribonuclease I (dornase alfa) is a highly safe effective treatment for complicated parapneumonic effusions (CPE) empyema. It improves drainage reduces surgical referral as well hospitalization length [1-3]. Clinical experiences dual tPA/dornase therapy ensuing rare complications are cumulating. CASE PRESENTATION: 49 year old female with past medical history hypertension, extensive tobacco use, IV drug use presented complaints right sided chest pain, productive cough blood tinged sputum, weight loss 2 weeks. Vitals were normal physical exam only significant decreased breath sounds. An initial CT demonstrated pleural effusion air-fluid level cavitary lesion 7 cm suggestive lung abscess. She was admitted to the floor antibiotics. On day 2, 10F pigtail catheter placed frank pus evacuated. Pleural fluid analysis showed WBC >800K cells/?L, glucose 10 mg/dL, LDH >40K IU/L, protein 3.1 gm/dL. The cultures grew Streptococcus intermedius. Repeat tube in position without communication between empyema abscess.On 4, two rounds 10mg tPA 5mg dornase alfa administered facilitate drainage. next day, an additional 250 mL bloody output noted from development new air leak. repeat revealed improvement subcutaneous emphysema. visualization previously described be open cavity.She transferred ICU close observation management due bronchopleural fistula (BPF). larger 16F aid reduce After days, patient no longer experiencing leak subsequently had removed on hospital 7. discharged home extended oral amoxicillin-clavulanic acid follow-up clinic. DISCUSSION: This case describes complication that can happen when using tpa/dornase presence abscess which lead BPF result rupture into cavity. As our literature review, we could not find any reported cases similar development, however, it bleeding prolonged use. CONCLUSIONS: Standard 3 reducing intervention, important appreciate arise abscesses. There should monitoring upon utilization therapy. REFERENCE #1: Rahman, N.M., et al., Intrapleural DNase infection. N Engl J Med, 2011. 365(6): p. 518-26. #2: Majid, A., Concurrent Instillation Tissue Plasminogen Activator Infection. Single-Center Experience. Ann Am Thorac Soc, 2016. 13(9): 1512-8. #3: Piccolo, F., Dis, 2015. 7(6): 999-1008. DISCLOSURES: No relevant relationships by Mohammed Al-Ourani, source=Web Response Rami Batarseh, Belete Desimmie, Anup Kumar, Kelsey Marshall,