A 33-year-old Native American man, a welder by profession, with a past medical history significant for alcohol use, hypertension, and asthma presented to the hospital with complaints of cough with occasional bloody sputum production. His cough started four days before presentation, was initially dry but progressively worsened, and became productive. It was also associated with dyspnea and orthopnea along with new-onset lower extremity edema. He further endorsed preceding nausea, vomiting, and diarrhea without abdominal pain, melena, or hematemesis. He reported an extensive history of alcohol consumption and had quit smoking 6 years ago.
On physical examination, he appeared restless and his vitals comprised a temperature of 98.5 F, blood pressure 158/91 mm of Hg, respiratory rate 30 breaths/minute, pulse 116 beats/minute, oxygen saturation 96% on 2 liters of supplemental oxygen via a nasal cannula, weight 290 pounds, and a body mass index of 39.32. His pertinent laboratory findings included a white blood cell count of 16.3 K/uL, hemoglobin 8.6 g/dL, platelets 124,000 K/uL, potassium 3.0 mEq/L, sodium 125 mEq/L, magnesium 1.6 mg/dL, folate level 5.7 ng/mL, creatinine kinase 455 U/L, lactate dehydrogenase 310 U/L, albumin 2.9 g/dL, CRP 16.9 mg/L, lactic acid 3.1 mmol/L, procalcitonin 0.14 ng/mL, and D-dimer 10.56 ug/mL FEU. His ethanol level was 96.7 mg/dL, while liver function tests showed aspartate transaminase 132 U/L, alanine transaminase 33 U/L, and alkaline phosphatase 219 U/L. Testing for SARS-CoV-2, Human Immunodeficiency Virus (HIV), influenza, and methicillin-resistant Staphylococcus aureus (MRSA) nasal screen was negative.
His computed tomographic angiogram of the chest (Figure 1) revealed bilateral infiltrates more extensive on the left as compared to the right and excluded pulmonary embolism. Ultrasound abdomen revealed hepatomegaly. An echocardiogram showed an ejection fraction of 65-70% with moderate left ventricular hypertrophy, left atrial enlargement, and right atrial dilation. He was started on empiric treatment with ceftriaxone 2 gm daily and doxycycline 100 mg twice a day for suspected bacterial pneumonia along with management of possible alcoholic hepatitis with thiamine and folic acid and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.
On day 2 of hospitalization, his hemoptysis and breathing deteriorated, and his white cell count rose further to 18.1 K/uL. His supplemental oxygen requirements increased, and chest X-ray (CXR) (Figure 2(a)) showed worsening left-sided infiltrates. Following this, the antibiotic regimen was broadened to cefepime 2 gm three times a day for 8 days and vancomycin dosed by the pharmacy for 5 days. Urine Legionella antigen, Streptococcus pneumoniae direct antigen, Aspergillus, Blastomyces, Coccidiodes, histoplasma antibodies, and repeat SARS-CoV-2 testing were all negative. Blood cultures and sputum cultures were obtained and were found to have no growth. Bronchoscopy was performed revealing DAH thought secondary to pulmonary edema. Intravenous (IV) steroids were started, and further infectious and autoimmune workup was undertaken. Bronchoalveolar lavage sampling was negative for acid-fast bacilli, Nocardia cultures, and CMV DNA. With the continued decline in respiratory function, he underwent endotracheal intubation.
While on mechanical ventilation, aggressive diuresis was initiated for pulmonary edema. Thereafter, he was weaned off the ventilator and extubated within a week. His hemoptysis resolved, but he continued to cough with infrequent mucoid phlegm. Antibiotics were discontinued after ten days when he was clinically better, and repeat CXR exhibited slight improvement in left-sided infiltrates along with the resolution of his right lung consolidation.
Steroids were transitioned from IV to oral prednisolone 40 mg daily for 26 days followed by a taper to cover for suspected alcoholic hepatitis. His mental function improved with alcohol withdrawal treatment and he became more alert and oriented. On further questioning, he recalled having exposure to sick kittens and mice few days before admission. He was tested for Hantavirus, Q fever, leptospirosis, and toxoplasmosis, and empiric treatment with doxycycline 100 mg twice a day was initiated for 3 weeks. TB testing (QuantiFERON, sputum acid-fast bacilli, and PPD) and antibodies for leptospirosis and Q fever were all negative.
On day 18, the patient was hemodynamically stable with complete resolution of respiratory failure and was deemed stable for discharge. Four days after discharge, Hantavirus IgM returned positive with equivocal IgG. Retrospectively, his presentation correlated with HCPS. Upon follow-up in the clinic 10 days after discharge from the hospital, he reported improvement in cough and dyspnea. Outpatient CXR (Figure 2(b)) revealed mild improvement of left upper lobe consolidation.