A 45-Year-Old Man With Dyspnea and Hypoxemia With Bilateral Pulmonary Infiltrates

A 45-year-old man presented with dyspnea and acute on chronic hypoxemic respiratory failure with progressive bilateral pulmonary infiltrates after surgical lung biopsy. His past medical history was pertinent for antiphospholipid syndrome (APS) treated with systemic anticoagulation. This diagnosis was made after aortic valve replacement for an aortic valve mass. Histopathology of the mass was consistent with a thrombus (Libman-Sacks endocarditis). Shortly after his diagnosis of APS, he developed progressive dyspnea and chest pain. CT imaging demonstrated bilateral pulmonary infiltrates, and review of prior available imaging confirmed these changes had been present during the evaluation period of his aortic mass. These symptoms progressively worsened and he presented to an outside hospital where he was found to have acute hypoxemic respiratory failure. He underwent bronchoscopy with bronchoalveolar lavage (BAL) and was diagnosed with bland pulmonary hemorrhage related to anticoagulation and was empirically treated with prednisone after infection was excluded. He improved clinically and symptomatically but his abnormal imaging findings were persistent on hospital follow-up with his pulmonologist. It was recommended that he undergo surgical lung biopsy for definitive diagnosis of his persistent pulmonary infiltrates. He was discharged home the day after his biopsy on 3 to 4 L/min of supplemental oxygen. Two days post-operatively, he presented with worsening dyspnea and hypoxemia. CT chest scan demonstrated worsening bilateral infiltrates. Notably, he decreased his dose of prednisone 1 week before the biopsy. He was transferred to our hospital for further evaluation.