EXPECT THE UNEXPECTED: FROM A DIAGNOSIS OF ILD TO NTM

SESSION TITLE: Chest Infections Case Report Posters 11 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: The incidence and prevalence of Nontuberculous mycobacteria (NTM) disease continues to increase worldwide and should be considered in the differential for interstitial lung disease (ILD) with suggestive radiographic patterns. We present a case with imaging findings and clinical picture that was very suggestive of chronic hypersensitivity pneumonitis who was eventually diagnosed with pulmonary NTM disease. CASE PRESENTATION: A 60 year old male with a past medical history of HIV on anti-retroviral therapy, former smoking presented to a pulmonary clinic with progressively worsening shortness of breath and an occasionally productive cough. He was treated with inhaler therapy and subsequently with antibiotics but did not improve. Computed tomography was performed which showed showed diffuse tree-in-bud centrilobular pulmonary nodular opacities. He received a diagnosis of ILD, was treated with corticosteroids and was then referred to our ILD clinic. We performed a bilateral bronchoalveolar lavage that showed significant lymphocytosis (70%) on the right and neutrophilia (62%) on the left. Cultures were negative. The differential diagnosis included ILD such as chronic hypersensitivity pneumonitis but also infectious etiologies such as NTM. Multidisciplinary recommendations were to pursue surgical lung biopsy to establish the diagnosis. Pathology showed bronchiolocentric chronic pneumonitis and well formed necrotizing granulomas. Subsequent cultures from the surgical specimen were positive for Mycobacterium abscessus supbsp. Massiliense. Patient was then referred to infectious disease for antimicrobial treatment. DISCUSSION: ILD and NTM can present with similar clinical pictures. The lack of improvement of our patient with corticosteroids, with persistent imaging findings and symptoms, to the background of severe alveolitis with both neutrophilic and lymphocytic components led to the decision to pursue a surgical lung biopsy for further elucidation of the underlying etiology, and determination of a treatment course: immunosuppression versus antibiotics. CONCLUSIONS: In certain presentations of ILD when NTM infection remains a concern, surgical lung biopsy should be considered prior to empiric immunosuppression, when other non-invasive testing is equivocal. REFERENCE #1: Donohue MJ, Wymer L. Increasing Prevalence Rate of Nontuberculous Mycobacteria Infections in Five States, 2008-2013. Ann Am Thorac Soc. 2016 Dec;13(12):2143-2150. doi: 10.1513/AnnalsATS.201605-353OC. PMID: 27681202. DISCLOSURES: No relevant relationships by Elie Fares Advisory Committee Member relationship with United Therapeutics Please note: 2022 Added 04/02/2023 by Gautam George, source=Web Response, value=Consulting fee No relevant relationships by Vani Mulkareddy