Cyberlindnera fabianii
is a yeast present in soil rarely associated with invasive infection. Due to advanced diagnostic and therapeutic techniques, pathogenicity is increasingly recognized.
A 37-year-old male with B cell lymphoma on rituximab developed multiple organ dysfunction syndrome secondary to
C. fabianii
bacteremia. Specialized species identification techniques were required after failure of standard methods. Despite extracroporeal membrane oxygenation (ECMO) the patient died on day 26 after admission.
A 21-year-old man presented with new-onset seizures and brain abscess. Echocardiography and cardiac magnetic resonance imaging revealed underlying Ebstein anomaly, secundum atrial septal defect, and cor triatriatum dexter. The elevated right heart pressures shunting through the septal defect and transient bacteremia were the likely mechanisms for his presentation. (
Level of Difficulty: Intermediate.
)
As the world learned about Covid-19, the application of ECMO also evolved as health systems in the United States had some time to prepare. We report our initial experience using extracorporeal support for Covid-19 patients with the resource challenges that attend a worldwide pandemic. Background: Extracorporeal support has improved survival in select neonatal and pediatric patients for over forty years. Over the last two decades, extracorporeal membrane oxygenation (ECMO) has emerged as an acceptable and potentially beneficial rescue modality in select adult populations. In severe respiratory failure, ECMO provides time for the lungs to rest and recover by augmenting gas exchange with the extracorporeal circuit. A review of the outcomes in patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) treated with ECMO demonstrated a decrease in hospital mortality rate and length of intensive care unit (ICU) stay compared to those managed with conventional therapy alone (1). Early reports regarding the use of ECMO in patients with Severe Acute Respiratory Distress Syndrome Coronavirus 2 (SARS-COV-2 or Covid-19) pneumonia have been mixed. Despite the similarities of MERS-CoV and the current novel coronavirus disease, recent reports have raised concerns regarding the high mortality rates observed in an early series of ECMO supported Covid-19 patients (2, 3). Similarly, a pooled analysis of five recent studies (4, 5, 6, 7, 8) suggested ECMO produced neither harm nor benefit in Covid-19 patients with ARDS. The authors of these analysis compared mortality in patients supported with ECMO for both MERS and Covid-19 and concluded Covid-19 patients had a significantly higher mortality than MERS (94.1% vs. 65.0%) when treated with ECMO. The authors further state that this data raises "questions about the real utility of ECMO in this outbreak" (8). Initial reports from United States hospital systems that had been both surprised and overrun with critically ill Covid-19 patients, demonstrated unfavorable results with supporting patients with ECMO, leading centers to abandon this support modality for these patients (9). We present a single-center analysis and preliminary outcomes regarding the use of ECMO in 15 patients with severe respiratory failure due to Covid-19 all of which had failed maximal conventional ventilatory management and interventions as presented. These initial promising results prompted communication of our experience, despite its preliminary nature.
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