A 21-YEAR-OLD MALE WITH A DEADLY COUGH

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coccidioidomycosis, commonly known as Valley Fever, is caused by Coccidioides immitis/posadasii species endemic to the Southwestern United States. Infection most commonly is asymptomatic, but rarely (1-4.7%) disseminated disease can occur, with mortality as high as 70%. The use of extracorporeal membrane oxygenation (ECMO) has rarely been reported, and never with a duration exceeding 90 days. CASE PRESENTATION: A 21-year-old African American male without significant past medical history, presented with one week history of dyspnea, back pain, and 10 lb weight loss. Chest X-ray showed diffuse bilateral interstitial infiltrates, and the patient was treated for community acquired pneumonia. However, the patient clinically deteriorated. Whole body CT revealed lytic bone lesions (multiple vertebrae, sacral, left scapula, and ribs) with diffuse pulmonary ground-glass and nodular opacities. A rib biopsy diagnosed disseminated coccidioidomycosis. Antifungal therapy was initiated, but the patient continued to worsen and developed acute respiratory distress syndrome (ARDS). He was failing conventional ventilator strategies and was eventually stabilized on ECMO. The patient underwent multiple surgeries to achieve source control. The patient was able to overcome the infectious process, with eventual lung recovery. He was decannulated after 90 days of ECMO and was discharged on life-long triazole therapy. He is currently finishing is college degree. DISCUSSION: Disseminated endemic fungal diseases, although rare, can be devastating. Despite antifungal therapy, our patient failed to improve. This was likely due to the severity of dissemination, particularly his osseous lesions. Surgical debridement is recommended for osseous lesions as antifungal therapy alone is likely to fail. Due to the severity of respiratory involvement, our patient also had to be supported on ECMO, which required continuous systemic anticoagulation to avoid circuit thrombosis. However, he had multiple spinal lesions that required debridement. Need for neurosurgery has previously been considered a relative contraindication to ECMO, however with careful management of anticoagulation these procedures can be done safely with minimal complications. Our patient underwent multiple neurosurgical procedures while on ECMO without significant hemorrhagic complications. CONCLUSIONS: There is a paucity evidence in the literature regarding the use of ECMO as salvage therapy for disseminated endemic fungal infections. Furthermore, surgical intervention has been considered a relative contraindication to ECMO, particularly neurosurgical intervention. Our case shows that not only can ECMO be used as a salvage therapy for ARDS due to disseminated coccidioidomycosis, but surgical interventions with high hemorrhagic risks can be performed with deliberate and strategic anticoagulation planning. Reference #1: Galgiani, J. N. Coccidioidomycosis. West J Med. 1993; 159:153-171. Reference #2: Studemeister, A., Studemeister, L. Brun, F. The role of extracorporeal membrane oxygenation in severe pulmonary coccidioidomycosis. Heart Lung. 2018; 47(3), 261–263. Reference #3: Combes, A., Hajage, D., Capellier, G., et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018; 378:1965–1975. DISCLOSURES: No relevant relationships by Andrew Berglund, source=Web Response No relevant relationships by Thomas Lee, source=Web Response no disclosure on file for Phillip Mason; No relevant relationships by Michael Moulton, source=Web Response No relevant relationships by Whittney Warren, source=Web Response No relevant relationships by Joseph Yabes, source=Web Response