Bachar Samra MD1, Jacques Azzi MD1, Ambreen Khalil MD2. Fatal Complication of Immunosuppressive therapy for Cryptogenic Organizing Pneumonia (COP) associated with Mycoplasma pneumonia in a Healthy Patient. Bachar Samra MD1, Jacques Azzi MD1, Ambreen Khalil MD2. COP, also known as Bronchiolitis obliterans with organizing pneumonia (BOOP), is characterized by inflammation of the small airways of the lungs, primarily affecting the alveolar ducts and interstitium and presence of granulation tissue within the alveoli. It is usually idiopathic but is sometimes associated with other etiological agents such as Nocardia, Mycoplasma, Human Immunodeficiency Virus (HIV) and Coxiella We present a case of biopsy-proven COP associated with Mycoplasma pneumonia that was further complicated by cytomegalovirus (CMV) pneumonitis in a previously healthy patient. 1. Medical resident, Department of Medicine, Staten Island University Hospital, # 475 Seaview Avenue, Staten Island, NY 10305, USA.   2. Assistant Director, Department of Infectious Diseases, Staten Island University Hospital, # 475 Seaview Avenue, Staten Island, NY 10305, USA.

Case presentation A 72 year-old healthy male presented with dry cough of four-month duration with progressive dyspnea and high grade fevers that developed a week before admission. Clinical exam was remarkable for fever and bilateral crackles Computed tomography of chest showed bilateral interstitial infiltrates with basilar and peripheral predilection and interlobular septal thickening. VTAS/lung biopsy proved the diagnosis of COP Mycoplasma pneumonia confirmed with IgM and IgG and treated with 10 day course of levofloxacin followed by clinical detoriation/ARDS/intubation. High dose steroids then azathioprine were initiated. BAL showed atypical cells characteristic of CMV. Intravenous ganciclovir was administered as salvage therapy but his respiratory status continued to decline and he expired.

Microscopic pathology photomicrograph of the COP Discussion While the majority of reported cases responded to therapy with steroids, our patient followed an unusually aggressive course. His clinical course was complicated by CMV pneumonitis, which resulted in acute respiratory distress syndrome and death. The patient’s immune status was compromised due to high dose steroids and azathioprine that were deemed necessary for treatment of underlying COP. However, this strategy also led to development of opportunistic infection with CMV with fatal outcome. Invasive and timely interventions such as bronchoscopy may be indicated in immunosuppressed patients for earlier detection and treatment of such infections. Microscopic pathology photomicrograph of the COP bilateral interstitial infiltrates with peripheral predilection and interlobular septal thickening.