SHM Converge Scientific Abstract ePoster Gallery-Diagnostic Uncertainty in a Steroid-Responsive Lung Disease in an Immunocompromised Patient

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This case highlights the diagnostic challenge of unexplained dyspnea in immunocompromised patients, where infection and volume overload are often the leading considerations, but steroid-responsive inflammatory lung diseases can closely mimic both.<br /><br />A 51-year-old woman with HIV on Biktarvy and end-stage renal disease on hemodialysis presented with progressive dyspnea, nonproductive cough, and pleuritic chest pain. She denied orthopnea and peripheral edema. Exam showed decreased breath sounds and mild bilateral lower-lobe crackles without signs of fluid overload. Initial imaging suggested severe multifocal pneumonia and possible pulmonary edema. However, an extensive evaluation for infectious, cardiac, and autoimmune causes was unrevealing, including negative respiratory viral testing, fungal and blood cultures, TB studies, and other pathogen testing. BNP and troponin were only mildly elevated, and echocardiography was normal. Bronchoalveolar lavage showed 13% eosinophils.<br /><br />Because she did not improve with diuresis and hemodialysis, empiric intravenous solumedrol was started after discussion with Pulmonary and Infectious Disease. She improved rapidly, with resolution of cough and dyspnea and discontinuation of supplemental oxygen within three days. Repeat chest CT demonstrated dramatic radiographic improvement. She was discharged on an oral steroid taper with pulmonary follow-up.<br /><br />The most likely diagnosis was acute eosinophilic pneumonia rather than cryptogenic organizing pneumonia, supported by BAL eosinophilia and the rapid clinical and radiographic response to corticosteroids. This case underscores that steroid-responsive lung disease can masquerade as pneumonia or volume overload in immunocompromised patients. Early recognition is essential to avoid prolonged hypoxia, unnecessary antimicrobial exposure, and delayed recovery. Multidisciplinary evaluation was key to reaching the correct diagnosis and optimizing outcome.

Asset Subtitle

Maxwell Su

Meta Tag

Author List Jennifer Li, Maxwell Su, Nebil Ahmed, Taylor Yoder, William Breaux

Category Clinical Vignettes

Concept Daptomycin-induced acute eosinophilic pneumonia

Concept Cryptogenic Organizing Pneumonia

Concept Steroid-Responsive Pulmonary Disease

Concept Dyspnea

Concept Glucocorticoid Therapy

Distinguished Non-Finalist

Presenter Organization Emory University

Presenting Author Maxwell Su

Track Adult

Keywords

acute eosinophilic pneumonia

dyspnea

immunocompromised

HIV

hemodialysis

steroid-responsive

bronchoalveolar lavage eosinophilia

multifocal pneumonia

pulmonary edema

corticosteroid therapy

Daptomycin-induced acute eosinophilic pneumonia

Cryptogenic Organizing Pneumonia

Steroid-Responsive Pulmonary Disease

Dyspnea

Glucocorticoid Therapy