Case of the week 48/2016
A clinical experience of using extracorporeal cytokine adsorption device (CytoSorb) in a case of Dengue fever
Khan, Z.A. Noble Hospital, Magarpatta Road, Hadapsar, Pune-411028, India.
This case study reports on a 32 year old male patient who was transferred to atertiary ICU with worsening multi organ failure, after presenting to a local hospital with fever, chills, dyspnea, yellow discoloration of skin and sclera the previous week
Case presentation
On admission the patient was pyrexic (100oF, heart rate 120 – 130 bpm, respiratory rate 26 – 30 per min, leukocytosis 16,400 µl, with acute organ dysfunction (agitation, thrombocytopenia, hypoxia, kidney dysfunction, metabolic acidosis and arterial hypotension), sepsis and septic shock. His APACHE score on admission was 27.
Within 24 hours the patient needed to be mechanically ventilated because of worsening Acute Respiratory Distress Syndrome (ARDS) and hypoxia
The patient received fluid optimization, nutritional support, antibiotics, proton pump inhibitors, treatments for hepatic encephalopathy, blood products and other standard support therapy
Treatment
CytoSorb was added as a supportive therapy due to the systemic inflammatory response and multiple organ dysfunction
The patient received three sessions of six hours each on days 2, 4 and 6 of admission.
No anticoagulation was used, blood flow rate was 250 mL/min
Measurements
Clinical and laboratory parameters before and after CytoSorb treatment: Creatinine, hematocrit, leucocytes, platelets, mean arterial pressure (MAP), ARF – Acute Renal Failure, GCS – Glasgow Coma Scale, aPTT – Activated Partial Thromboplastin Time, GOT – Serum Glutamic Oxaloacetic Transaminase (AST), GPT – Serum Glutamic Pyruvic Transaminase (ALT)
Arterial blood gas values before and after CytoSorb therapy: pH, PaCO2 – Partial Pressure of Carbon Dioxide, PaO2 – Partial Pressure of Oxygen, SBC – Standard Bicarbonate, (A-a) O2 – Alveolar-arterial oxygen gradient mmHg, Base Excess
Results
There were no major complications during or after the CytoSorb therapy except mild irritability that settled with sedatives
Patient showed gradual improvement with APACHE score after the third cycle decreasing from 27 to 12
As a result of the treatment:
Creatinine decreased from 3.96 to 1.59 mg/dL
Leucocytes from 16,3000 to 13,000 /µL
Platelets from 50,000 to 311,000 /µL
GCS from 9 to >10
Mean arterial pressure from 84 to 104 mmHg
aPTT from 43 to > 60 seconds, GOT (AST) from 15690 to 156 U/L, GPT (ALT) from 3910 to 84 U/L
Serum lactate from 6.7 to 1.9 mmol/L
Post-treatment period and follow-up
Patient was transferred from ICU on day 13, and subsequently discharged fully ambulant.
CONCLUSIONS
CytoSorb helped to stabilize and revive this patient with dengue, MODS and shock.
The majority of laboratory parameters were within the normal range after the therapy and no major adverse events were reported during or after the CytoSorb therapy.
This is the first report of the clinical application of CytoSorb hemoadsorption in a case of dengue fever with MODS treated successfully with standard of care along with CytoSorb
CytoSorb seems to be an interesting and safe option to stabilize and help dengue patients with MODS to recover
