A CASE OF HEMORRHAGE RESCUED BY EXTRACORPOREAL MEMBRANE OXYGENATION

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a well-known complication of many disease processes including vasculitides. DAH secondary to vasculitis, however rare, is one of the most devastating presentations of vasculidities carrying a substantial mortality. A significant percentage of patients with DAH progress to acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been described to improve oxygenation in ARDS while underlying etiologies are addressed. The role of VV ECMO in DAH secondary to vasculitis is unclear. CASE PRESENTATION: A 37-year-old woman presented with severe ARDS. In the preceding two weeks, she experienced polyarthralgias and a lower extremity rash. She presented to the emergency department after developing hemoptysis which necessitated intubation. On presentation to the intensive care unit, she was afebrile and had an oxygen saturation of 95% on an FiO2 of 1. Of note, the patient had non-blanching, palpable, hemorrhagic bullae. Lab-work was notable for a white blood cell count of 13,600, a hemoglobin of 8.4 g/dL, a PaO2/FiO2 (P/F) ratio of 92, and urinalysis with protein and dysmorphic red blood cells. Computed tomography of the chest demonstrated diffuse infiltrates sparing the periphery. She was paralyzed and placed in a prone position for severe ARDS. She was started on pulse-dose steroids and on plasma exchange for suspected DAH. On day three, her P/F ratio was 61 and she was placed on VV ECMO. Bronchoscopy was performed with sequentially bloodier returns on alveolar lavage. Further workup revealed negative bacterial cultures, a positive ANA titer of 1:320, a C-ANCA titer of 1:40, and an elevated PR3 antibody. The patient was diagnosed with granulomatosis with polyangiitis and was started on cyclophosphamide. She was decannulated from ECMO after four days, extubated two days thereafter, and was discharged from the hospital in her premorbid state. DISCUSSION: The causes of DAH are varied but are commonly due to autoimmune phenomena. The current evidence for use of ECMO in DAH is limited to case reports and case series. Before the more widespread deployment of extracorporeal support, the treatment of respiratory failure from DAH was limited to aggressive ventilator management and immunomodulating medications. Despite progress in immunosuppressive therapy, the mortality for DAH remains unacceptably high. The deployment of ECMO may provide enough time with sufficient oxygenation for the causes of DAH to be addressed. CONCLUSIONS: Though there is a dearth of high-quality evidence justifying the use of ECMO in DAH, our case demonstrates that VV ECMO can be used successfully to temporize the hypoxemia in DAH. This measure could provide the time necessary for immunosuppression to take effect and reduce overall mortality from the most devastating consequence of vasculitis. Reference #1: Park M. S. (2013). Diffuse alveolar hemorrhage. Tuberculosis and respiratory diseases, 74(4), 51-62. Reference #2: Guo, Z., Li, X., Jiang, L. Y., & Xu, L. F. (2009). Extracorporeal membrane oxygenation for the management of respiratory failure caused by diffuse alveolar hemorrhage. The journal of extra-corporeal technology, 41(1), 37-40. Reference #3: West S, Arulkumaran N, Ind PW, Pusey CD. (2013). Diffuse Alveolar Haemorrhage in ANCA-associated Vasculitis. Internal Medicine, 52(1):5-13. DISCLOSURES: No relevant relationships by Lisa Daniels, source=Web Response No relevant relationships by Joshua Detelich, source=Web Response No relevant relationships by Maxwell Hockstein, source=Web Response