HYPERSENSITIVITY PNEUMONIA: NARY A CANARY AROUND. WHAT GIVES?

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tumor necrosis factor alpha (TNFa) inhibitors are often used to modulate overactive inflammatory mechanisms in numerous rheumatological conditions. Acute lung injuries (ALI) rare but known complications of TNFa inhibitors. Most literature suggests a transient injury that resolves with medication cessation, occasionally addition steroids. We describe rapidly worsening hypersensitivity pneumonia which led death. CASE PRESENTATION: fifty-three-year-old woman past medical history significant for well-controlled moderate persistent asthma (FEV1 76% predicted), psoriatic arthritis (PA), and obstructive sleep apnea. She had been on methotrexate her PA quite some time change due adverse effects. was approved switched adalimumab. Within 2 months, she presented cough mild progressive dyspnea exertion. Computed tomography (CT) imaging concerning interstitial disease (ILD) usual pattern. For further evaluation, biopsy performed discharged supplemental oxygen. Biopsy results indicated "mild lymphocytic infiltration poorly formed granulomas within airspaces interstitium an underlying pattern fibrosis peribronchiolar metaplasia fibrotic (HP)". The pathologists felt these changes were not consistent those seen association other medications or concluded acute DISCUSSION: Due symptoms, started steroid taper nintendanib. There improvement initially stabilization oxygen needs developed bilateral pneumothoraces requiring rehospitalization. recovered also mycophenolate began the discussion transplant. following day, however, hospitalized hypoxic respiratory failure recurrent pneumothorax. required intubation acidosis refractory mechanical ventilation. initial tests transplant transitioned extra-corporeal membrane oxygenation prior transfer accepting center, died soon after. CONCLUSIONS: While most TNFa-associate ALI cases relatively mild, one must be aware processes like HP can lead Some evaluation ILD, possibly chest versus functions might considered initiation TNFa. REFERENCE #1: Patel BV, Wilson MR, O'Dea KP, Takata M. TNF-induced death signaling triggers alveolar epithelial dysfunction injury. J Immunol. 2013;190(8):4274-4282. doi:10.4049/jimmunol.1202437 DISCLOSURES: No relevant relationships by Nikhil Meena, source=Admin input Speaker/Speaker's Bureau relationship GSK Please note: March 2020-May 2021 Added 05/05/2021 Daniel Paul, input, value=Honoraria Eric Peeler, source=Web Response