SEVERE RHABDOMYOLYSIS AND ARDS SECONDARY TO ADENOVIRUS IN A MORBIDLY OBESE YOUNG PATIENT: A THERAPEUTIC DILEMMA

Abstract

SESSION TITLE: Critical Care 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Severe rhabdomyolysis due to adenovirus and acute respiratory distress syndrome due to adenovirus have been well reported in literature. However, there are no case reports presenting together in a single patient. CASE PRESENTATION: 50 years old morbidly obese male(>500 lbs) with past medical history of OSA (on CPAP qHS), diabetes who presented with progressively worsening shortness of breath, productive cough with yellowish sputum and fever 101 at home. In ED, he was febrile to 103F, tachycardic 107, RR 22, BP 130/80, SpO2 96% on non re-breather. CXR on admission was suggestive of pulmonary edema and initial labs were significant for acute renal failure with a progressively rising creatinine from 1.5 mg/dl to 5mg/dl within 6 hours and initial creatinine phosphokinase(CPK) levels of >200000 which progressively rose inspite of aggressive fluid resuscitation. He was placed on Bi-level non invasive ventilation without improvement and was subsequently intubated a few minutes later for refractory respiratory failure. He was later found to be positive for adenovirus. Further clinical course was complicated by progression to acute respiratory distress syndrome (ARDS), requirement of renal replacement therapy, and need for vasopressors. Although his PaO2/FiO2 ratios were <100 post intubation on maximal ventilatory support, given his morbid obesity, prone ventilation was not considered. We approached our ECMO team and the patient was placed on veno-venous ECMO within 24 hours of intubation. Afterwards, he showed slow improvement over the next few weeks and eventually underwent tracheostomy and percutaneous endogastric tube placement. He was eventually discharged from our hospital after a prolonged stay of almost 60 days. DISCUSSION: Rhabdomyolysis due to adenovirus is mainly due to viral myositis. CPK values can exceed >800,000. Most cases of ARDS due to adenovirus have been in morbidly obese patients who were not candidates for proning but received paralytics and ECMO. There are no specific recommendations for management of ARDS due to adenovirus, potential agents are cidofovir and brincidofovir, however, their use is limited due to severe nephrotoxicicty and myelosuppression. CONCLUSIONS: The lack of concrete recommendations or guidelines for management of adenovirus induced ARDS makes management difficult. When complicated by rhabdomyolysis which requires fluid resuscitation in the initial stages, maintaining euvolemic status for the management for ARDS complicates management even further. In the above case, the patient was successfully managed with early initiation of RRT and ECMO although we avoided use of antivirals in the absence of concrete literature to support their use. Reference #1: Tseytlin, D., & Maynard, S. (2016). Severe rhabdomyolysis secondary to adenovirus infection: case report and literature review. Clinical nephrology, 85(4), 245-250. Reference #2: Severe ARDS caused by adenovirus: early initiation of ECMO plus continuous renal replacement therapy Reference #3: Kam, M., Chai, H. Z., Goh, K. J., Tan, Q. L., Sewa, D. W., Tan, A. H., … & Phua, G. C. (2017). The Use of Extracorporeal Membrane Oxygenation in Severe Adenovirus Pneumonia Complicated by ARDS: A Single-Center Experience. Chest, 152(4), A350. DISCLOSURES: No relevant relationships by Animesh Gour, source=Web Response no disclosure on file for Anisha Kamath; No relevant relationships by Mangalore Amith Shenoy, source=Web Response