A 42-year-old woman was admitted with dyspnea and enduring cough for several days. Although she had not suffered from any underlying illness, she had administered oseltamivir for influenza A (H1N1) which had been diagnosed using polymerase chain reaction (PCR) in a local clinic 4 days ago. When she was admitted, her vital signs were as follows: blood pressure, 90/60 mm Hg; pulse rate, 100 beats per minute; respiratory rate, 22 breaths per minute; and body temperature, 36.3℃. Oxygen saturation was 93.3% with 2 L/min of oxygen via nasal cannula. On auscultation of her chest, coarse breathing sounds were noted in both lung fields. Chest X-ray showed peribronchial consolidations, and multifocal ground glass opacities in both hilar areas (
Figure 1). Laboratory findings revealed hypoxemia on the arterial blood gas analysis (pH, 7.390; PCO
2, 27.9 mm Hg; PO
2, 67.9 mm Hg; bicarbonate, 17.0 mmol/L), hemoglobin of 13.8 g/dL, white blood cell count of 4,640 cells/mm
3 (neutrophils, 77.4%), and platelet count of 161,000 cells/mm
3. Other findings showed C-reactive protein of 30.24 mg/dL, serum albumin of 3.7 g/dL, aspartate aminotransferase of 35 U/L , alanine aminotransferase of 27 U/L, total bilirubin of 0.9 mg/dL, and serum creatinine of 1.8 mg/dL. Chest computed tomography (CT) presented tracheobronchial wall thickening, multifocal patchy consolidations and nodular opacities with cavitations on both lungs (
Figure 2). Bronchoscopy showed severe mucosal inflammation with sloughing and diffuse cobblestone-like multiple mucus swelling of exudates in whole bronchial tree, causing partial obstruction of airways, consistent with pseudomembranous tracheobronchitis (
Figure 3). We couldn't perform bronchoscopic biopsy because she was severely desaturated during the procedure. After bronchoscopy, respiratory failure occurred and she was transferred to the intensive care unit to start the mechanical ventilation. Methicillin-sensitive
Staphylococcus aureus (MSSA) was isolated from bronchial washing fluid. Acid fast bacillus stain and PCR for
Mycobacterium tuberculosis were negative. Serum galactomannan test was negative. With the diagnosis of the pseudomembranous tracheobronchitis following influenza, we changed the antibiotics to ciprofloxacin and amoxicillin/clavulanate against MSSA. D uring mechanical ventilation, she required tube thoracotomy for bilateral pneumothoraces. In addition, infected pneumatoceles occurred, so that we drained the fluid from infected pneumatocele using a pigtail catheter and changed antibiotics to colistin against multi-drug resistant
Acinetobacter baumannii which was isolated from the fluid in infected pneumatocele. After improvement of dyspnea and radiologic findings of chest X-ray, we could remove the pigtail catheter (
Figure 4). The follow-up bronchoscopy showed much improvement (
Figure 5), and she was discharged to home on 52nd hospital day.