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Use of hemadsorption in pediatric meningococcal sepsis, Waterhouse-Friderichsen-Syndrome, and multiple organ failure
Guido Mandilaras, Simone Katrin Dold, Robert Dalla Pozza Division of Pediatric Cardiology and Pediatric Intensive Care, University Hospital, LMU Munich, Munich, Germany. Open Journal of Clinical & Medical Case Reports 2022; 8(12):1889
12/13/2022
New!PediatricsReduction in catecholaminesSafetySeptic ShockAnticoagulation HeparinCase of the weekCase reportCritical CareCRRT (pre or post filter)Inflammatory parameters
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Summary
CoW 42/2022 – This case reports on an 18-year-old male without relevant medical history, who presented at the emergency room of a peripheral primary care hospital with nausea and headaches.
Summary
Community-acquired bacterial meningitis still represents one of the most important infectious diseases worldwide and remains a substantial cause of mortality and morbidity, particularly in both the very young and the elderly patients. The disease is characterized by a hyperinflammatory response with a rapid and excessive production of inflammatory mediators, accompanied by disseminated intravascular coagulation (DIC) and development of Waterhouse–Friderichsen syndrome. Extracorporeal blood purification therapies represent a new therapeutic approach since they seem to be able to attenuate this detrimental process by lowering systemic cytokine levels. We herein report on an 18-year-old previously healthy male who had to be intubated and mechanically ventilated shortly after hospital admission followed by confirmation of Neisseria meningitidis infection. Antibiotic as well as catecholamine and volume therapy were initiated. Over time he developed excessive hyperinflammation, Waterhouse-Friderichsen-syndrome with purpura fulminans, hyperlactatemia and progressive renal failure, leading to the initiation of combined renal replacement and CytoSorb hemoadsorption therapy. This resulted in significant decrease in inflammatory parameters and a progressive reduction in catecholamine and lactate levels while peripheral perfusion was restored preventing any loss of extremities. The patient could be extubated 10 days after PICU admission. No adverse or unwanted device-related side effects were documented. In conclusion, this case report is supporting other promising results in this highly sensitive patient cohort, by showing rapid hemodynamic stabilization and control of hyperinflammation being associated with the use of CytoSorb, however, evidence on the application of the CytoSorb adsorber in pediatrics remain rather sparse and more clinical data are needed.
Case presentation
During the hospital admission process, the patient rapidly developed petechiae over his entire body, resulting in the preliminary diagnosis of meningococcal sepsis
Following initiation of antibacterial therapy with cefotaxime (2 x 4g iv) and ampicillin (3 x 5g iv) as well as administration of dexamethasone (3 x 10 mg iv), the patient had to be intubated due to respiratory insufficiency and a central venous and arterial catheters were inserted
Subsequently, catecholamine (norepinephrine 0.8 mg/h) and volume therapy (2 l isotonic saline, 2000 IE prothrombin complex, 2x fresh frozen plasma, 1x platelet concentrate) were started due to progressive hemodynamic instability
Microbiological analysis of the liquor puncture confirmed presence of Neisseria Meningitidis type B bacteria
The mechanically ventilated patient was then transferred under ongoing catecholamine therapy to the pediatric intensive care (PICU) unit for further diagnosis and therapy
At this time, clinically the patient was exhibiting a picture of full-blown Waterhouse-Friderichsen-syndrome with purpura fulminans accompanied by ubiquitous petechial hemorrhages and hyperlactatemia (max. 10.8 mmol/l)
Hydrocortisone administration was started according to the guidelines (50 mg/m² body surface) along with sedation with midazolam, and sufentanyl, which was later complemented by propofol and dexmedetomidine
Antibiotic therapy was supplemented by tobramycin and his disseminated intravascular coagulopathy (DIC) was treated by means of repeated doses of fresh frozen plasma, platelet concentrates, and vitamin K
Echocardiography revealed a restricted cardiac function with an ejection fraction of 31% and inotropic therapy was extended by epinephrine and milrinone, accordingly
Mechanical ventilation had to be intensified because of increasing bronchial secretions and left atelectasis (max positive end-expiratory pressure [PEEP] 10 mbar)
Due to progressive renal failure with elevated retention parameters, continuous renal replacement therapy (CRRT) was started five hours after PICU admission and approximately twelve hours later a CytoSorb hemoadsorber was additionally added to the circuit to control excessive hyperinflammation (Interleukin – IL-6 >200,000 pg/ml)
Treatment
Two CytoSorb treatment sessions were performed for a total duration of approximately 50 hours
CytoSorb was used in combination with CRRT run in continuous veno-venous hemodiafiltration (CVVHDF) mode
Blood flow rate: 120 ml/min
Anticoagulation: heparin
Measurements
Hemodynamics and catecholamine requirements
Inflammation
Lactate
Respiratory status
Cardiac function
Sequelae of DIC
Results
Therapy resulted in early and rapid hemodynamic stabilization accompanied by a prompt decrease in norepinephrine and epinephrine doses. The epinephrine infusion could already be tapered off at the end of the second hemoadsorption session
During combined CVVHDF and hemoadsorption treatment, there was also a significant decrease in inflammatory parameters noted, pointing towards control of the hyperinflammatory state. IL-6 levels reduced from >200,000 to 770 pg/ml within the first 48 hours of combined therapy
Lactate levels also reduced progressively
The respiratory situation stabilized during treatment and cardiac function started to improve
Additionally, there were no further petechial hemorrhages, and no peripheral ischemia observed with no loss of extremities in the follow-up period
Patient Follow-Up
Continuous hemodiafiltration was switched to intermittent dialysis as renal function consecutively improved as evidenced by a normalization in retention parameters and return of spontaneous diuresis
The pulmonary situation slowly improved with inhalation and repeated bronchoscopy with bronchial lavage, so that the patient could be extubated 10 days after PICU admission
Ongoing follow-up was characterized by mild delirium and development of critical illness neuropathy with pronounced tremors, which, however, resolved during his stay
Two weeks after admission to the PICU, the patient was transferred to the general pediatric ward in a stable clinical condition with a normal cardiac function (EF 70%) and was discharged from the hospital shortly afterwards
Conclusions
Treatment in this adolescent patient with meningococcal sepsis, Waterhouse-Friderichsen-Syndrome, and multiple organ failure was associated with a rapid and significant reduction in plasma cytokine levels, accompanied by improved hemodynamics, normalization of plasma lactate levels and restored peripheral perfusion preventing any loss of extremities
As such, this case report supports other promising results in this highly sensitive patient cohort
The very positive clinical course in our case does not imply that there was relevant removal of any of the antibiotics used
No adverse or device-related side effects were documented during or after the treatment sessions and the combination was practical, technically feasible and appeared to be highly beneficial for the patient.
