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Division of Surgery, Department of Transplant Surgery, Medical University of Graz, Judith.kahn{at}klinikum-graz.at (Kahn, Müller) Division of Anesthesiology, Medical University of Graz (Kulier, Keusch-Preininger) Division of Surgery, Department of Transplant Surgery, Medical University of Graz (Tscheliessnigg)
To the Editor:
We present a case of severe acute respiratory distress syndrome caused by systemic leptospirosis that we successfully managed with veno-arterial extracorporeal membrane oxygenation. The most frequent zoonosis in the world (1), leptospirosis is endemic to tropical regions. It can also appear in developed countries (1,2) and is a possible cause of acute respiratory distress syndrome. Pulmonary involvement, usually consisting of hemorrhagic pneumonitis, varies from 20% to 70% (3) and can be fatal (4–8).
One week after returning from Thailand, our patient's flu-like symptom required acute hospitalization. Three days later, he required endotracheal intubation and mechanical ventilation. Chest radiograms revealed diffuse bilateral infiltrates. Bronchoscopy showed diffuse endobronchial bleeding, possibly secondary to coagulopathy. His sepsis-related organ failure scores were 4 for respiration, coagulation, liver, cardiovascular system, and renal function and 1 for central nervous system. The patient was treated with amoxicillin/clavulanate (Augmentin) and clarithromycin. His respiratory status worsened, with progressive hypoxia and evidence of pulmonary hypertension. An echocardiogram showed atrial fibrillation with a frequency of 110–120 bpm. Cardiac ultrasound revealed right ventricular overload. His pulmonary artery pressure was estimated to be 60 mm Hg. Central venous pressure was 22 mm Hg, and the arterial blood pressure was 95 mm Hg. The pulmonary hypertension was unresponsive to inhaled nitric oxide and prostacyclin.
We placed the patient on veno-arterial extracorporeal membrane oxygenation, which immediately improved his oxygenation and hemodynamic status. A subsequent microagglutination test confirmed a diagnosis of leptospirosis. The patient was treated with imipenem and ciprofloxacin. Acute renal failure required continuous hemofiltration for 3 days. The patient steadily improved, and he was weaned off extracorporeal membrane oxygenation after 60 h. His subsequent hospital course was unremarkable, and 26 days after admission the patient was discharged from the hospital.
We recommend testing for leptospirosis to screen for infection of unknown origin. Early extracorporeal membrane oxygenation treatment may be lifesaving for patients with acute respiratory distress syndrome that does not respond to conventional therapy.
References
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