A Total White Out Lung After Bronchial Alveolar Lavage

Abstract

Serious complications from bronchoalveolar lavage (BAL) are uncommon but have been reported. The most common complications of BAL include transient hypoxemia, post-BAL fever, bronchospasm, increased pulmonary infiltrate and rarely pneumothorax. We present a case of a ruptured lung abscess leading to necrotizing pneumonia, a rare but serious complication of BAL. 60-year-old male with history of polysubstance, tobacco and chronic alcohol abuse, hypertension, diabetes, liver cirrhosis and chronic right middle lobe lesion requiring hospitalization and prolonged antibiotics few months ago presented to the hospital with two days of hemoptysis and right-sided chest pain. A computed tomography angiography (CTA) chest ruled out a pulmonary embolism but showed worsening right middle (RML) and upper lobe (RUL) cavitary lesions. Bronchoscopy and BAL with 90cc of normal saline revealed blood oozing from the RML with mucosal thickening and cultures grew Klebsiella pneumoniae. Few hours after the procedure, the patient had worsening respiratory symptoms, a Chest x-ray showed a total right lung white out. Subsequently, CTA chest revealed hydropneumothorax and increased pleural effusion. Chest tube was inserted and later he underwent a right thoracoscopic decortication with wedge resection. The patient was started on 4 weeks of IV antibiotic with cefazolin and metronidazole, he was discharged soon after. Guidelines for approaching to cavitary lesions diagnosis are lacking. Bronchoalveolar lavage is commonly performed as the first line of investigation for most of pulmonary diseases with abnormal imaging findings. Though BAL is overall considered a safe procedure, rarely a severe complication may arise. Although most complications are related to extent of lavaged lung area, volume and tempreture of instilled fluid, it is difficult to determine the risk factors that predispose to the rupturing of cavitary disease from BAL due to its rarity. Our patient had an extended period with untreated cavitary disease. The chronicity of the cavitary disease may be one risk factor as spontaneous cavitary rupture has been associated with delayed diagnosis and treatment. Performing BAL with lesser volume of instilled fluid and applying gentle negative pressure to aspirate fluid might decrease the complications although there are no significant data supporting this.