(1220) Brewing Trouble: Alcohol-Related Necrotizing Pneumonia

Introduction: Alcohol consumption alters the microbiome and weakens the immune system, as well as affects defense mechanisms throughout the respiratory tract making those with alcohol use disorder more susceptible to pneumonia with atypical organisms. The following case demonstrates a young woman who developed an empyema due to extended-spectrum beta-lactamase (ESBL) Escherichia coli.

Description: A 37-year-old female with a history of alcohol use disorder presented with fever, chills, and dyspnea. She was tachycardic, hypotensive, with significant leukocytosis. Upon admission, the patient presented with severe respiratory distress requiring high-flow oxygen and vasopressor support due to septic shock and acute hypoxic respiratory failure. She was placed on IV antibiotics and high dose steroids. CT of the chest revealed complete lack of aeration of the left lung, requiring thoracentesis with pigtail placement. She remained febrile, tachycardic, with an increasing leukocytosis, and worsening pneumonia on CT. She then underwent a VATS and decortication. Repeat respiratory culture grew ESBL E. coli and antibiotics were adjusted. Her oxygen requirements decreased, however, she continued to be febrile, tachycardic, with persistent leukocytosis. CTA performed was consistent with necrotizing pneumonia and potential bronchopleural fistula. Due to lack of significant clinical improvement, she was transferred to a tertiary care center for surgery evaluation.

Discussion: It is rare for E. coli and other gram-negatives to be the cause of empyema in healthy individuals. E. coli resides in intestinal microflora, commonly causing UTIs, diarrhea, and peritonitis. An empyema is primarily induced by S. pneumonia, S. aureus, or anaerobes, except in those with cirrhosis or immunocompromised. Alcohol impairs immune function by decreasing bacterial clearance and ciliary function in the respiratory tract; alcohol diminishes alveolar macrophage’s ability to release cytokines, participate in oxidative metabolism, recruit neutrophils, and ingest bacteria. Given her lack of comorbidities, this patient’s clinical course was likely intensified by her diminished immune system in the setting of her extensive alcohol history, illustrating the importance of considering atypical pathogens in those with a history of alcohol abuse.