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EP.210
VV-ECMO Resistant Hypoxia and RV Failure in a case of PVL-MSSA Community Acquired Pneumonia

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VV-ECMO Resistant Hypoxia and RV Failure in a case of PVL-MSSA Community Acquired Pneumonia

Dr James Wilson, Dr Francisca Caetano, Dr Richard Fisher, Dr James Doyle, Dr ShahanaUddin, Prof Susanna Price; AICU, Royal Brompton Hospital, London

Introduction

Panton-Valentine leucocidinis acytotoxinproduced by certain Staphylococcus aureus 
Causessevere tissue necrosis, including the lung [1]. 
Affects ~2%% of staphylococcal community acquired pneumonia [1]

Case report

54-year-old type 2 diabetic admitted for community acquired pneumonia; sputum positive for methicillin-sensitive Staphylococcus aureus(MSSA) subsequently found to be PVL positive
Admitted to ICU but despite appropriate medical treatment continued deterioration. Referred for retrieval on VV-ECMO

Initial management at ECMO Centre

Admission CT (Figure 1) showed extensive consolidation of both lungs. Transthoracic echocardiogram (TTE) demonstrated normal biventricular function but signs of elevated pulmonary vascular resistance.
Despite adequate VV-ECMO flows and circuit change patient remained consistently hypoxic (PaO8.7kPa
Additional strategies considered (including utilising a secondary oxygenator) but started to show improvement on standard VV-ECMO. Target PaO2> 6kPa (saturations >80%) accepted
On day 7:  ECG demonstrated new RBBB -> TTE found low cardiac output state due to acute cor-pulmonale with severe right ventricular (RV) dilatation(Figure 2) -> Milrinone started. 

Outcome

Underlyinglung pathology slowly improved, allowing weaning of VV-ECMO, milrinone and vasopressor support. 
Serial TTE showed partial resolution of the acute RV failure but persistent pulmonary hypertension -> sildenafil started. 
Tracheostomy inserted and on sedation hold neurological examination normal
Decannulated from VV-ECMO on day 43and was repatriated to his local hospital at day 47.

Summary & Discussion

While use of VV-ECMO in treatment of PVL pneumonia has been described previously [2,3], in this  case:
- The severity proved resistant to VV-ECMO support and so relative hypoxaemia was accepted
- The degree of acute RV dysfunction reflected the severity of the underlying pulmonary pathologyhighlighting the importance of regular TTEin patients with severe respiratory conditions such as these.
Despite the critical illness patient made a good clinical recovery with no gross signs of neurological deficit.

Figure 1: CT Thorax

Saggitalsection of CT Thorax in case of PVL-MSSA demonstrating extensive consolidation and lung destruction. Ao; aorta, LPA; left pulmonary artery, RPA; right pulmonary artery, C; cavity, ECMO; extracorporeal membrane oxygenation cannulae(arrowed)

Figure 2: Transthoracic echocardiogram

Transthoracic echocardiogram (parasternal short axis view) in a patient with acute cor-pulmonale relating to PVL-MSSA. LV; left ventricle, RV; right ventricle, IVS; inter-ventricular septum, coll; pericardial collection


References

[1] Shallcross LJ, FragaszyE, Johnson AM, Hayward AC. The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13:43-54

[2] Fujisawa N, Takahashi A, Arima T, Mizushima T, Ikeda K, KakuchiH, et al. Successful Treatment of Panton-Valentine Leukocidin-expressing Staphylococcus aureus-associated Pneumonia Co-infected with Influenza Using Extracorporeal Membrane Oxygenation. In Vivo. 2014;28:961-65

[3] LavoueS, Le GacG, GacouinA, RevestM, SohierL, MoulineJ, et al. Extracorporeal circuit for Panton-Valentine leukocidin-producing Staphylococcus aureus necrotizing pneumonia. Med Mal Infect. 2016;46:314-17


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