Abstract
Pneumocystis pneumonia is a common complication of cellular immunosuppression and may trigger severe pulmonary complications. Rapid onset of acquired immunodeficiency syndrome is possible in infants infected with human immunodeficiency virus (HIV). We report here the case of a 13-week-old girl who was previously healthy presenting with altered immunity and refractory acute respiratory distress syndrome (ARDS) initially attributed to bacterial pneumonia. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated because her condition was poor. An HIV infection was later fortuitously diagnosed after accidental exposure of a nurse to the child's urine. The mother had congenitally transmitted HIV to the child after late (undetected) infection during pregnancy. The lung lesions were finally attributed to Pneumocystis pneumonia. We prescribed combined antiretroviral, antibiotic, and steroid therapy aimed at preventing immune reconstitution inflammatory syndrome. VV-ECMO weaning progressed over 30 days to the time of decannulation, rapidly followed by extubation and hospital discharge. The case highlights the fact that rare curable causes of refractory pediatric ARDS should always be investigated early. VV-ECMO should not be excluded as an ARDS treatment for immunocompromised children.
Highlights
Pneumocystis pneumonia is a common opportunistic infection in patients infected with human immunodeficiency virus (HIV) and can cause acute respiratory distress syndrome (ARDS) associated with a high mortality rate (up to 58% even in intensive care units (ICUs)) [1]
Conflicts of Interest e authors declare no conflicts of interest
human immunodeficiency virus (HIV): acute respiratory distress syndrome (ARDS): ICU: VVECMO: acquired immunodeficiency syndrome (AIDS): PEEP: ELSO: PALICC: RRT: Human immunodeficiency virus Acute respiratory distress syndrome Intensive care unit Venovenous extracorporeal membrane oxygenation Acquired immunodeficiency syndrome Positive end-expiratory pressure Extracorporeal Life Support Organization Pediatric Acute Lung Injury Consensus Conference Renal replacement therapy
Summary
Pneumocystis pneumonia is a common opportunistic infection in patients infected with human immunodeficiency virus (HIV) and can cause acute respiratory distress syndrome (ARDS) associated with a high mortality rate (up to 58% even in intensive care units (ICUs)) [1]. Venovenous extracorporeal membrane oxygenation (VV-ECMO) for adults with acquired immunodeficiency syndrome (AIDS) is generally associated with favorable outcomes [2,3,4,5]. No pediatric case has been described; the utility of VVECMO in children is questionable. Pediatric HIV infection can rapidly evolve to AIDS before 2 years of age; Pneumocystis pneumonia is not rare in patients with vertically transmitted HIV [6, 7]. We present here the case of a congenitally HIV-infected infant who developed ARDS associated with refractory hypoxemia and Pneumocystis pneumonia. VV-ECMO, combined with cotrimoxazole and a corticosteroid, allowed complete respiratory function recovery. e HIV infection was fortuitously diagnosed, suggesting that immunosuppression status had not been adequately screened
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