Rothia mucilaginosa pneumonia complicating interstitial lung disease.
Bachert HD, and Thavarajah K. Rothia mucilaginosa pneumonia complicating interstitial lung disease. Am J Respir Crit Care Med 2018; 197.
Am J Respir Crit Care Med
Rothia mucilaginosa is a gram-positive coccus found in the human oropharynx and upper respiratory tract which can cause opportunistic infections in hosts who are immunocompromised or have impaired pulmonary defense. We share a rare case of Rothia mucilaginosa pneumonia identified during workup of suspected Hypersensitivity Pneumonitis. Case Report A 63 year-old male with a remote history of tobacco use, nonalcoholic steatohepatitis-related cirrhosis, post liver transplant 1 year prior complicated by dermatologic and gastrointestinal graft-vs-host disease (GVHD) presented to the Interstitial Lung Disease (ILD) clinic with progressive dyspnea with exercise, nonproductive cough, and fatigue. He denied fevers, chills or night sweats. His anti-rejection regimen consisted of tacrolimus. Prednisone had been tapered off 2 months prior to presentation. His exposures included frequent hot tub use. Cardiopulmonary physical exam was only remarkable for chronic lower extremity edema. Pulmonary function tests (PFTs) revealed a forced vital capacity (FVC) of 4.12 L (77% predicted) and diffusion capacity (DLCO) 16.4 mL/mmHg/min (56% predicted), both significantly lower from 1 year prior. Echocardiogram did not show evidence of pulmonary hypertension. There was no neutropenia or lymphopenia. A mildly elevated ANA and low titer myeloperoxidase antibody were suspected to be GVDH related per Rheumatology. High resolution chest computed tomography (HRCT) showed progression of peripheral reticulation, scattered septal thickening, ground glass opacities, and lower lobe air-trapping compared to CT prior to liver transplant, lowering suspicion of tacrolimus-induced toxicity or GVHD. The patient was instructed to avoid hot tub use for suspected Hypersensitivity Pneumonitis. Bronchoscopy revealed Rothia mucilaginosa on bronchoalveolar lavage and evidence of acute and chronic interstitial inflammation on transbronchial biopsies. On reevaluation, he recalled dental work in the months prior to presentation. He was prescribed a 12-week course of Penicillin 500 mg every 6 hours. He reported improvement in dyspnea and cough within 1 week of starting antibiotics. He abstained from further hot tub use. Eight weeks later, the FVC and DLCO significantly improved, and HRCT showed improvement in ground glass opacities. Discussion Rothia mucilaginosa pneumonia has been reported in patients with hematologic malignancies, neutropenia with central venous catheters, and impaired pulmonary clearance. Third generation cephalosporins, high dose Ampicillin, Vancomycin, Rifampicin, Chloramphenicol, and Penicillin are reported to have activity against Rothia. The improvement in pulmonary infiltrates could be attributed to removal of hot tub exposure alone. However, the symptomatic improvement shortly after initiation of antibiotics points to the contribution of Rothia pneumonia to this presentation of ILD.