Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review

Abstract

BackgroundPulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO).Case presentationA 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients’ pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support.ConclusionECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.

Extracorporeal Membrane Oxygenation in a 29-Year-Old Man with Pneumocystis jirovecii Respiratory Failure and AIDS

“…18 Only a few patients with HIV infection or full-blown AIDS have been treated with ECMO (Table III). [9][10][11][12][13][14][15][16][17] Because of low CD4 cell counts and at least one opportunistic infection, almost all had new diagnoses of HIV with AIDS. Initial concerns about using ECMO to treat HIV-infected or AIDS patients focused on possibly increasing immune suppression.…”

Veno-Venous Extracorporeal Membrane Oxygenation for Severe <i>Pneumocystis jirovecii</i> Pneumonia in an Immunocompromised Patient without HIV Infection

“…The evidence of efficacy of V-V ECMO for severe respiratory failure is increasing (Kolla et al 1997;Linden et al 2000;Davies et al 2009;Peek et al 2009); however, it is still unknown what kind of patients with severe respiratory failure could be saved with V-V ECMO assist. Several cases of PJP in HIV-infected patients were successfully managed with V-V ECMO (Cawcutt et al 2014;Ali et al 2016;Mauri et al 2016;Horikita et al 2017;Lee et al 2017;Morley et al 2017;Capatos et al 2018;Ramanathan et al 2018). As non-HIV PJP more frequently progresses to respiratory failure compared with HIV PJP, non-HIV PJP could be the indication for V-V ECMO assistance.…”

Severe acute respiratory distress syndrome in a patient with AIDS successfully treated with veno‐venous extracorporeal membrane oxygenation: a case report and literature review

“…The indications for ECMO remain controversial, especially in patients who are immunosuppressed or have non‐recoverable comorbidities. There are several reports of successful ECMO use for severe hypoxia in patients with HIV/AIDS 2, 3, 4, 5, 6, 7, 8, 9, 10. However, key therapeutic issues, such as mechanical ventilation (MV) settings, indications for ECMO, and the timing of antiretroviral therapy (ART), have not always been discussed in these reports.…”

“…There are several reports of successful ECMO use for severe hypoxia in patients with HIV/AIDS. [2][3][4][5][6][7][8][9][10] However, key therapeutic issues, such as mechanical ventilation (MV) settings, indications for ECMO, and the timing of antiretroviral therapy (ART), have not always been discussed in these reports. A case of acute respiratory distress syndrome in a patient with novel HIV/ AIDS, who was successfully treated with veno-venous (V-V) ECMO and discharged, is presented.…”