SEVERE PULMONARY LEPTOSPIROSIS REQUIRING ECMO

Abstract

SESSION TITLE: Chest Infections 3 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 11:00 AM - 12:00 PM INTRODUCTION: Severe pulmonary disease due to Leptospira spp. is an infrequent complication of systemic infection and may be under-recognized in endemic areas. It can be manifested by pulmonary hemorrhage and ARDS with associated multisystem organ failure to include hepatic, renal and CNS manifestations. In patients with pulmonary leptospirosis in endemic areas, the mortality may be over 75%. We report the use of extracorporeal membrane oxygenation (ECMO) for a patient with severe leptospirosis infection. CASE PRESENTATION: The patient was a 47-year-old male who traveled to Jamaica for his honeymoon and returned with general malaise. He was admitted to an outside facility where he was found to have hyperbilirubinemia, thrombocytopenia, and acute kidney injury. His course progressed and he developed massive hemoptysis for which he was intubated and required high ventilatory support to maintain oxygenation. Due to progressive renal failure, he was initiated on CRRT; however, despite attempts at ultrafiltration, he became volume overloaded over several days. He was transferred to our facility and placed on ECMO due to worsening oxygenation. Infectious Disease consultation confirmed the diagnosis of leptospirosis-induced vasculitis. Initial head CT imaging after transfer demonstrated bilateral subarachnoid hemorrhages and subgaleal hemorrhage with later development of large left frontal intracerebral hemorrhage following EVD placement for elevated CSF pressures. In addition to ECMO, he required plasma exchange due to liver failure for hyperbilirubinemia and as well as CRRT for anuric renal failure. Over the next two weeks, he developed worsening CNS changes consistent with uncal herniation. MRI was obtained and demonstrated diffuse axonal injury with greater than right anterior frontal intraparenchymal hemorrhage extending into both lateral ventricles and layering within both occipital horns. Due to progressive uncal hernation, hypotension, and worsening hypoxemia, the patient expired several days later. DISCUSSION: Massive pulmonary hemorrhage and vasculitis due to leptospirosis is uncommon and often associated with multi-organ system failure. Several case reports have described the successful use of ECMO in the setting of massive pulmonary hemorrhage. These cases were also complicated by thrombocytopenia, hepatic, and renal failure but did not report CNS involvement. An important adjunct in these cases was maintaining airway patency with use of bronchoscopy. CONCLUSIONS: Clinicians should consider ECMO as a possible rescue therapy for patients with pulmonary leptospirosis. Reference #1: Hery G, Letheulle J, Flecher E, et al. Massive intra-alveolar hemorrhage caused by leptospira serovar Djasiman in a traveler returning from Laos. J Travel Medicine 2015; 22 (3):212–214. Reference #2: Arokianathan D, Trower K, Pooboni S, et al. Leptospirosis: a case report of a patient with pulmonary haemorrhage successfully managed with extra corporeal membrane oxygenation. J Infection 2005; 50(2):158-162. Reference #3: Liao CY, Ben RJ, Wu HM, et al. Acute respiratory distress syndrome manifested by leptospirosis successfully treated by ECMO. Int Med (Japan) 2015; 54 (22):2943-46. DISCLOSURES: No relevant relationships by Mauer Biscotti, source=Web Response No relevant relationships by Andrew Hersh, source=Web Response No relevant relationships by Matthew Koroscil, source=Web Response Speaker/Speaker's Bureau relationship with Janssen Pharmaceuticals Please note: $1001 - $5000 Added 11/27/2017 by Michael Morris, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with Vyaire Medical Please note: $1001 - $5000 Added 11/27/2017 by Michael Morris, source=Web Response, value=Consulting fee No relevant relationships by Robert Walter, source=Web Response