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Disseminated Pasteurella multocida pleuropulmonary disease in a patient using short duration oral glucocorticoids and absence of bite

We seek to highlight the degree of immunocompromise that can be affected by short courses of oral glucocorticoid therapy, well below the threshold of what is commonly considered to be ‘immunosuppressant’. The present case describes a severe and disseminated Pasteurella multocida bacteraemia with pleuropulmonary infection in a woman traditionally considered ‘immunocompetent’, potentially glucocorticoid use may have contributed to the disease severity. We describe a 56-year-old woman with a pet dog and respiratory history of mild asthma with infrequent shortacting beta-agonist usage. Admission was preceded by 3-days of dyspnoea, managed with 3 days of oral prednisolone 37.5 mg for presumed asthma exacerbation. Presentation was prompted by fevers and respiratory deterioration with profound distributive shock requiring inotropic supports for 6 days, with a maximal requirement of noradrenaline 60 mcg/min. Type-1 respiratory failure warranted early intubation. Imaging suggested left lower lobe consolidation (Fig. 1A). Gram-negative bacilli in blood cultures were detected and identified as P. multocida on Day 3. Despite inotropes ceased and successful extubation, deterioration at Day 10 prompted repeated imaging revealing an 8-cm multi-loculated pulmonary abscess with pleural collection suggestive of empyema (Fig. 1B). Left lower lobectomy revealed histology consistent for pulmonary abscess and no organism detection. Intravenous benzyl-penicillin was continued 1-week postoperatively and transitioned to oral amoxicillin for 6 weeks with complete recovery. The patient’s Jack Russell was of good health with no animal-related injuries identified. Recurrent sinopulmonary or gastrointestinal infections and comorbidities increasing immune-suppression risk including diabetes, chronic kidney disease, liver disease, multiple myeloma or human immunodeficiency virus were excluded. No previous corticosteroids were used to manage asthma. Primary or secondary immunodeficiency investigations returned normal immunoglobulin levels, lymphocyte subsets and complement pathway function. Humoral immunity with antibody response to pneumococcal vaccination generated a robust serological response. Infection with P. multocida is acquired from domestic animals manifesting as localised skin and soft tissue infection following bites. In the immunocompromised host, rates of disseminated infection are notably higher. Pasteurella multocida infection in the absence of animal bite is associated with higher rates of co-morbidities, immune-suppression, infection severity, complications and mortality. P. multocida is implicated in pleuropulmonary infections where underlying respiratory disease is associated with higher mortality. Kopita et al. described 108 cases of P. multocida pleuropulmonary infections with 49 cases of pneumonia, 25 empyemas, 3 pulmonary abscess and 55% of patients with bloodstream infection. Ninetythree percent of cases identified underlying risks for severe disease, with 29% mortality rate associated with pleuropulmonary infection. Glucocorticoids have pleotropic effects on the immune system, including decreased inflammatory cytokine transcription, abrogation of neutrophil phagocytic function,