A Rare Case of White-out Lung Due to Intrapleural Hemorrhage after the Administration of tPA and DNase

This chapter reports a case of white-out lung due to intrapleural hemorrhage after the administration of tPA and DNase in a patient previously not on any anticoagulation, with complicated parapneumonic effusion. Pleural infection is increasing worldwide with many reports showing significant rises in the incidence over the last few decades. Because of their mucolytic activity, tissue plasminogen activator (tPA) and recombinant deoxyribonuclease (D Nase) are used to treat pleural infections by successfully lowering the viscosity of the pleural fluid. In high-risk patients who are not suitable candidates for surgery, the combination of tPA plus DNase has garnered significant interest as a treatment option for complex parapneumonic effusion. We report a case of 57-year-old female with a medical history of hypertension, chronic kidney disease stage 3A, opioid use disorder on methadone maintenance program (MMTP), heart failure with reduced ejection fraction, and hypothyroidism presented to the emergency department (ED) with complaints of generalized diffuse headache for three days after she ran out of her hypertensive medication. A chest tube was placed with drainage of fluid while tPA and DNase were also considered as an additional treatment module. After receiving the initial dosage of DNase and tPA, the patient had hypoxemia and hypotension. Additionally, a rapid development of right hemothorax was observed.