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Use of CytoSorb in septic shock with ARDS in the context of pneumonia and pulmonary hemorrhage with suspected macrophage activation syndrome in systemic lupus erythematosus
Dr. Klaus Kogelmann | Interdisciplinary Intensive Care Medicine, Emden Hospital, Germany
04/06/2022
New!Other indicationsReduction in catecholaminesSafetySeptic ShockImprov. resp functionAnticoagulation CitrateARDSCase of the weekCase reportCritical CareCRRT pre filterInflammatory parameters
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Summary
CoW 14/2022 – This case reports on a 35-year-old female patient with systemic lupus erythematosus who presented to hospital with exacerbated encephalopathy under the assumption of an infection after she was found apathetic, disoriented and somnolent, lying at home by the ambulance service.
Case presentation
Her vital signs on admission were as follows: blood pressure 117/79 mmHg, heart rate 103/min, respiratory rate 20/min, body temperature 37.7°C, SaO2 99% on room air
Since her discharge from hospital two weeks previously (initial diagnosis of lupus at that time), she had had recurrent fevers up to 39 degrees, progressive deterioration in her general condition, heavy sweating, as well as diarrhea, nausea, vomiting and associated difficulties with food intake (including her necessary medication such as diclofenac, pantoprazole, metamizole, prednisolone). In addition, she complained of a cough which had been getting worse by the day, and a 2-day history of visual disturbances, lack of concentration, disorientation, and hallucinations
Next to the lupus diagnosis she had a history of tuberculosis in 2000. The patient had up to this point refused any vaccinations against COVID-19 due to an unclear allergy, however, the current COVID-19 PCR test proved negative
The patient was initially admitted to the monitoring station due to symptomatic hyponatremia in the context of persistent vomiting and diarrhea. Under intravenous fluid and NaCl substitution, her clinical condition improved transiently
Due to the dyspnea and cough which had been progressing for several days, the radiological findings and a history of known tuberculosis, miliary tuberculosis was ruled out (PCR negative). Until results were available, the patient was treated empirically with a 4-drug therapy (ethambutol, pyrazinamide, isoniazid, rifampicin)
Then, two days after hospital admission, there was an acute respiratory deterioration requiring emergency intubation
Clinical (bronchoalveolar lavage) and radiological findings revealed pulmonary hemorrhage because of her systemic lupus erythematosus
This was accompanied by a septic/inflammatory picture with markedly elevated procalcitonin (PCT 15.8 pg/ml), C-reactive protein (CRP 60.9 mg/l) and ferritin (4322 ng/ml) levels
Given the pronounced hemodynamic instability, a cardiac output-guided (PiCCO) sepsis therapy consisting of volume, vasopressors and empirical antibiotic therapy (piperacillin/tazobactam) was started
In addition, high-dose hydrocortisone administration (1 g for 5 days) was initiated
At this time, she developed oliguric acute renal failure. Given the pronounced hemodynamic instability with the need for increasing doses of catecholamines (norepinephrine 2.7 mg/h) as well as pronounced hyper-lactatemia (7.7 mmol/L), a CytoSorb hemoadsorber was indicated from the authors’ point of view, which was subsequently initiated together with continuous renal replacement therapy (CRRT)
The diagnosis was septic shock with acute respiratory failure (ARDS) in the context of pneumonia and pulmonary hemorrhage (cumulatively, the patient received a total of 3 units of packed red blood cells)
Treatment
A total of 4 consecutive treatments with CytoSorb were performed over the following 3 days (treatment 1 and 2 for 12 hours each, treatment 3 and 4 for 24 hours each)
CytoSorb was used in combination with CRRT (Multifiltrate, Fresenius Medical Care) run in continuous veno-venous hemodialysis (CVVHD) mode
Blood flow rate: 100-200 ml/min
Anticoagulation: Citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Hemodynamics and catecholamine doses
Inflammatory parameters
Oxygenation
Results
During the course of the treatment, norepinephrine dosages could be gradually reduced. Already after 7 hours, it could be reduced to 1.6 mg/h and could finally almost completely be discontinued 24 hours after the end of the 4 treatments
CytoSorb treatment was also associated with control of hyperinflammation with a clear reduction in inflammatory parameters (CRP 9.2 mg/l, PCT 2.8 pg/ml 24 hours after the last treatment)
Oxygenation also improved under the combined therapy (P/F ratio before starting CytoSorb 88 mmHg and 24 hours after the last treatment 244 mmHg)
Patient Follow-up
In the context of the clinical picture of an acute abdomen (presumably paralytic ileus) necessitating increasing ventilatory pressures, an abdominal CT was inconclusive, and there was a slight improvement under bowel stimulation
After clear clinical stabilization (hemodynamically stable, minimal catecholamine dosages, and pulmonary improvement), hemodialysis and cytokine adsorption were discontinued and weaning from the respirator commenced
In view of the findings (systemic hyperinflammation, hemorrhage, pancytopenia, ferritin increase, hyponatremia) and after a telephone consultation with colleagues from the rheumatology department of the Red Cross Hospital in Bremen, a macrophage activation syndrome (Hemophagocytic Lymphohistiocytosis – HLH in the context of systemic lupus erythematosus) was decided to be the most conclusive
Transfer of the patient to Münster University Hospital for further diagnosis and antibody therapy of lupus erythematosus
At the time of transfer, the patient was still analgosedated and ventilated, but hemodynamically stable
Conclusions
In this patient with septic shock and ARDS in the context of pneumonia and pulmonary hemorrhage as well as suspected macrophage activation syndrome in the context of systemic lupus erythematosus, combined treatment consisting of standard therapy, CytoSorb hemoadsorption and renal replacement therapy resulted in a significant stabilization in hemodynamics with a reduction in norepinephrine dose, control of the hyperinflammatory situation as well as a significant improvement in respiratory function
Treatment with CytoSorb was safe and feasible without technical problems.
