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CytoSorb in a patient with post-COVID 19 mucormycosis, septic shock and multiple organ failure
Dr. Hardik Gajera | Gujarat Kidney & Superspeciality Hospital, Gujarat, India
11/17/2021
New!SafetyViral infectionImprov. resp functionAnticoagulation HeparinCase of the weekCase reportCOVID-19Critical CareCRRT pre filterFungal infectionInflammatory parameters
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Summary
CoW 46/2021 – This case reports on a 47-year-old male who was admitted to the Emergency Room with tachypnea, hypotension, and post-COVID-19 mucormycosis.
Case Presentation
On examination, vital signs included a respiratory rate of 42/min, blood pressure 70/40 mmHg, and an SpO2 96% on room air
The patient had a history of cardiovascular stroke 6 years previously and had undergone a right hemi-maxillectomy two weeks before admission
He was afebrile on admission but was diagnosed with having Acute Kidney Injury (AKI – creatinine >3 mg/dl). The patient was also found to have a serous fungal infection (rhino-sinus mucormycosis post-COVID 19) following post-admission diagnosis via a nasal endoscopy biopsy specimen
Arterial blood gas analysis showed the patient had a pH of 7.40, pCO23 mmHg, pO2 82 mmHg, bicarbonate 16.4 mmol/L, total carbon dioxide (tCO2) 14.6 mmol/L
The given values pointed towards reduced oxygen capacity resulting in the diagnosis of an acute lung failure, so he was placed on non-invasive Biphasic Positive Airway Pressure (BiPAP) therapy
Moreover, due to the ongoing hypotension, the patient was placed on vasopressin therapy and norepinephrine
Additional laboratory examination revealed the following: Total Leucocyte Count (TLC) 42,280/mm3, serum creatinine 3.58 mg/dL, C-Reactive Protein (CRP) 226 mg/L, Procalcitonin (PCT) 100 ng/ml confirming a severe systemic hyperinflammatory state, most probably associated with a cytokine release syndrome progressing to septic shock involving multiple organs (lungs, kidneys, cardiovascular)
Additionally, the patient was placed on intravenous antibiotic therapy including teicoplanin 400mg (twice daily on the first day and daily thereafter) and meropenem (1 mg three times daily)
In view of his deteriorating clinical condition despite maximum standard therapeutic measures the patient was placed on CytoSorb therapy which was integrated into the hemodialysis machine
Measurements
Hemodynamics
Inflammatory markers
Oxygenation
Renal function
Treatment
One CytoSorb adsorber was used over the course of 16 hours
CytoSorb was used in combination with a conventional hemodialysis machine
Blood flow rate: 200 ml/min
Anticoagulation: heparin 200 IU, aPTT (seconds): 50
CytoSorb adsorber position: pre-dialyzer
Results
Over time, the patient hemodynamically stabilized (BP 120/82 mmHg) and could be weaned off vasopressors over 5 days
Post-CytoSorb therapy, CRP reduced from 226 mg/L to 27.80 mg/L
The patient had a major improvement in his oxygenation(pO2 82 mmHg to 376 mmHg). Oxygen therapy was able to be gradually tapered and eventually weaned off completely on day 5
Additionally, a decrease in creatinine was observed (3.58 mg/dl to 2.38 mg/dl) following cessation of CytoSorb therapy indicating recovery of his renal function
Patient Follow-Up
The patient was placed on broad-spectrum antifungal liposomal amphotericine b (300 mg/250 mg in 5% dextrose) and continued until the treatment was completed to ensure the complete removal of mucormycosis preventing infectious flare-ups
The patient was discharged in a clinically stable condition 9 days after his initial admission
Conclusions
In this case of a patient with post-COVID 19 mucormycosis with septic shock associated with multi-organ dysfunction syndrome (MODS), the application of CytoSorb hemoadsorption therapy in conjunction with hemodialysis resulted in stabilization of hemodynamics, control of the hyperinflammatory response as well as an improvement in oxygenation and renal function
Despite the patient being infected by the serious but rare black fungus mucormycosis, he recovered completely. This might point towards the effectiveness of CytoSorb as a potential rescue therapy in patients with fungal complications
The therapy was well-tolerated with no adverse effects.
