LAUSR

Learning Objectives: We describe a case of Stenotrophomonas matophilia bacteremia with disseminated infection, including fatal hemorrhagic pneumonia and metastatic nodular skin lesions. Methods: 52 year-old-woman with refractory ALL, prolonged pancytopenia receiving salvage chemotherapy (Methotrexate, Vincristine, 6-Mercaptopurine, Prednisolone) and undergoing evaluation for bone marrow transplant presented with one day neutropenic fever of 101. Patient did not have respiratory symptoms or hypoxia, however chest x-ray showed lower lobe infiltrates and she was started on empiric daptomycin and meropenem with preliminary blood cultures showing gram-negative rods. The second day of hospitalization, blood cultures returned with Stenotrophomonas maltophilia. Serial chest x-ray showed progressive disease and patient developed a new nodular erythematous lesion on chest wall. Antibiotics were narrowed to ceftazidime, She was also on amphotericin and isovuconazole given the concern for invasive fungal infection. Patient continued to rapidly decline with persistent high fevers to 103, shock, new productive cough, and hypoxemia. CT chest scan showed multifocal bilateral opacities with characteristics of fungal/opportunistic infection. She had progression of skin involvement, with development of multiple palpable nodular red lesions over her chest, arms, and legs. Skin biopsy showed 4+ Stenotrophomonas. Due to worsening clinical state, patient was explained poor prognosis, she verbalized and decided no resuscitation and comfort care. She subsequently developed rapid respiratory deterioration, hemoptysis, and died on hospital day four. Results: Hemorrhagic pneumonia due to Stenotrophomonas is a rare presentation, with 31 cases reported until 2016, that occurs in patients with hematologic malignancies and has 100% mortality in 72 hours. The most important risk factor is prolonged severe neutropenia. Metastatic infection may cause skin and eye involvement, endocarditis, and meningitis. Early suspicion and treatment is needed to improve survival as Stenotrophomonas is resistant to most empiric treatments for pneumonia in immunocompromised individuals and patients may rapidly decline before organism is detected.