We describe a 46-year-old splenectomized patient who died of Haemophilus Influenzae septicemia 16 h following bronchoscopy Although rare.

We describe a 46-year-old splenectomized patient who died of Haemophilus Influenzae septicemia 16 h following bronchoscopy Although rare, postsplenectomy overwhelming sepsis is always a danger in splenectomized patients undergoing invasive manner of proceedings Chemoprophylaxis should be considered in asplenic patients peribronchoscopy.

(Chest 1993; 104:1607-09)

Fiberoptic bronchoseopy has been in regular use for more than 20 years. The rate of serious complications is excessively low[1,2] In a survey of 48000 acts only 12 deaths were reported-none from infectious causes.[2] Clinically significant bacteremia following bronchoscopy has been reported simply rarely,[3-6], and antibiotic prophylaxis is not recommended[7] Patients postsplenectomy are at risk for overwhelming infections, particularly from encapsulated organisms.[8] The following report is of a fatal case of septicemia following bronchoscopy in an asplenic patient. To our knowledge, this portrays the first report of overwhelming sepsis following bronchoscopy in a splenectomized patient.

Case Report

A 46-year-old man was diagnosed in June 1989 as suffering from Philadelphia chromosome-negative chronic myeloid leukemia. Initially he was treated with hydroxyurea and busulfan, nevertheless because of progressive splenomegaly, he underwent splenectomy in November, 1989 Twenty-three-valent pneumococcal vaccine (Pneumovax) was given prior to surgery Thereafter his disease was controll with busulfan for extended periods. In April 1992, he was hospitalized with a history of febrile disease dyspnea, and progressive bilateral interstitial infiltrates. Transbronchial biopsy specimens showed epithelial alveolar atypia and interstitial fibrosis compatible with drug-induced injury, presumably owed to busulfan. Bronchoalveolar lavage (BAL) did not reveal any infectious agent. Treatment with hydroxyurea and prednisone, 50 mg/d was started. The agitation partially responded but the interstitial infiltrates were unchanged. He underwent a repeated bronchoscopy four weeks following the initial examination. upon bronchoscopy, a large ammount of feculent secretions were seen in the bronchi. Bronchoalveolar lavage was performed the two in the right middle lobe and lingula. Transbronchial biopsy specimens were taken from the right middle and lower lobes. Immediately following the conduct the patient was mildly dyspneic and was kept below observation. Several hours later, the patient unfolded a high fever, hypotension, and worsening dyspnea. The patient was transferred to an ICU and was intubated. Because the hypotension did not reply adequately to fluids and vasopressors, a Swan-Ganz catheter was inserted. Measurements performed demonstrated a high cardiac output (12 L/min), a gentle systemic vascular resistance (2.5 forest units), and a low pulmonary capillary wedge urgency (3 cm [H.sub.2]O) compatible with the diagnosis of septic hostile encounter Despite maximal respiratory and cardiovascular support and treatment with multiple antibiotics, the patient died of progressive refractory hypotension and hypoxemia 16 h after the bronchoscopy improvements from BAL grew Haemophilus Influenzae and an identical organism grew in kin cultures taken prior to antibiotic theray. Silver stain of the BAL was positive for Pneumocystis carinii. Transbronchial biopsy specimens again showed changes compatible with busulfan damage and were similar to those obtained a month earlier. Permission for autopsy was denied.

Discussion

The risk of bacteremia during bronchoscopy (including transbronchial biopsies) is exceedingly depressed In four large studies consisting of a total of 297 patients undergoing bronchoscopy merely five patients had positive children cultures postbronchoscopy.[9-12] In four of them, there were no clinical signs and the organisms were probably skin contaminants. individual patient with a lung abscess had polymicrobial bacteremia the couple before and after bronchoseopy.[9] Searching the English literature, we could find simply five previous reports, three of them fatal, of clinically significant bacteremia following fiberoptic bronchoscopy and transbronchial biopsy.[3-6,13] These cases are summarized in Table 1

[TABULAR DATA OMITTED]

In adults, overwhelming postsplenectomy infections have been reported mainly in immunologically compromised patients and les commonly in normal asplenic hosts[8] Our patient was harshly immunocompromised due to the combination of chronic myeloid leukemia and corticosteroid therapy.

It is les likely that the immediate cause of death was either Pneumocystis carinii infection or busulfan lung damage, as death within hours in these conditions is extremely unusual. The rapidly fatal clinical course postbronchoscopy is typical of infection with encapsulated organisms in postsplenectomy patients.[8] We think that the patient had bronchitis owed to H Influenzae as manifested by way of the purulent secretions in the bronchi. During transbronchial biopsies, the bacteria was probably disseminated into the patient's bloodstream causing the rapidly fatal syndrome

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