SESSION TITLE: Infectious Disease Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Wednesday, October 29, 2014 at 11:00 AM - 12:15 PM
INTRODUCTION: Acute Respiratory Distress Syndrome (ARDS) is a disease with significant morbidity, mortality and cost. Pulmonary tuberculosis(TB) causing ARDS is rare. This case report describes a unique case of ARDS secondary to Pulmonary TB that was successfully managed with extracorporeal membrane oxygenation (ECMO).
CASE PRESENTATION: A 31 year-old Liberian male was transferred with progressive respiratory failure requiring mechanical ventilation. He presented with subacute onset of cough and dyspnea and a chest radiograph (CXR) depicting bilateral infiltrates and a small right pleural effusion. Bronchoscopy with bronchoalveolar lavage demonstrated AFB positive sputum cultures, and the patient was started on four drug therapy: isoniazid, rifampin, pyrazinamide and ethambutol. Influenza A and B virus testing as well as blood, sputum and urine cultures were negative. Upon arrival to our institution the patient was paralyzed, mechanically ventilated on 100% FiO2, PEEP of 12, and inhaled epoprostenol (100ng/kg/min). Initial arterial blood gas revealed: pH 7.3, pCO2 52, and pO2 of 98. The patient experienced worsening hypoxemia (oxygen saturation 78%, PaO2 51) on Pressure Control 22 cm (tidal volumes of 300mL), PEEP 16, 100% FiO2 and plateau pressures of 35cm. Recruitment maneuvers and attempts to increase mean airway pressures were limited by high plateau pressures. Repeat CXR at the time showed no change in the bilateral infiltrates and no pneumothorax. Veno-venous ECMO was initiated via an Avalon Elite® Catheter in the right internal jugular vein. He was successfully weaned from ECMO after nine days and was then successfully liberated from mechanical ventilation ten days later.
DISCUSSION: Pulmonary TB with acute respiratory failure requiring mechanical ventilation has been associated with mortality rates as high as 79%. While ARDS secondary to pulmonary TB has been reported, this is only the second reported case of TB associated ARDS successfully supported with ECMO.
CONCLUSIONS: The use of ECMO is a viable option as rescue therapy for refractory hypoxemia in severe ARDS caused by Pulmonary TB.
Reference #1: Kim YJ et al. Pulmonary Tuberculosis with acute respiratory failure. Eur Respir J 2008; 32: 1625-1630
Reference #2: Petrillo TM et al. Respiratory failure caused by tuberculous pneumonia requiring extracorporeal membrane oxygenation. Perfusion 2001; 16: 525-529
Reference #3: Lee PL, et al. Patient mortality of active pulmonary tuberculosis requiring mechanical ventilation. Eur Respir J 2003; 22: 141-147
DISCLOSURE: The following authors have nothing to disclose: Walter James, Lisa Brath, Orlando Debesa
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