CASE PRESENTATION
A
48-year-old male was transferred to our emergency department for
acute-onset
fever lasting for four days on November 1, 2019. The highest temperature
was
40℃.
He
traveled in many places in northern China (Yan’an, Beijing, Qinhuangdao
and so on) one month prior to admission. Treated in the local clinic 2
days ago, the symptoms of the patient were getting worse with
generalized cold limbs, exacerbated dyspnea and developed anuria. The
blood pressure was as low as 55/40mmHg, heart rate was 55 bpm, oxygen
saturation was 74%, and
the
skin mottling score (SMS) was 5 (Figure 1A, 1B ). His initial
vital signs in our hospital were as follows: respiratory rate: 22
breaths/min; heart rate: 136 beats/min; blood pressure: 136/100 mmHg;
the
temperature is too low to measure; and
oxygen
saturation, 100% on non-invasive ventilation treatment.
Auscultation
of the lungs revealed wheezes and crackles. Blood gas analysis showed
hypoxia and metabolic acidosis with hyperlactatemia. Laboratory studies
showed WBC: 8.97*10^9/L, N 84.1%, HB: 200 g/L, PLT 55*10^9/L, PCT
3.86ng/ml, CRP 94.40mg/L, APTT 104.0sec, LDH 4351U/L, high-sensitivity
troponin 36.14pg/mL, myoglobin 391ng/mL, BNP 209pg/mL. The results of
echocardiography
were unremarkable. The CT scan of the pulmonary
before admission showed bilateral
pulmonary infection with pulmonary edema and bilateral pleural effusion(Figure 2A) . Then,
the
patient was
admitted
to the ICU under the consideration of severe sepsis, septic shock,
moderate ARDS, bilateral pneumonia, pulmonary edema, and acute kidney
injury.
After admission, antibiotics (oseltamivir, Imipenem-Cilastin Sodium,
linezolid, moxifloxacin, and azithromycin),
hydrocortisone,
vasopressors
(norepinephrine),
and
immunotherapy
were initiated. Continuous renal replacement therapy (CRRT) and
mechanical
ventilation therapy were also initiated. The changes of body fluid and
adjustment of antibiotics shows in Figure 3.
Before introducing ECMO, the
mechanical
ventilator was set to the airway pressure-controlled mode
(positive
end-expiratory pressure, 12 cm H2O; fraction of inspired
oxygen, 0.6). The pre-ECMO implantation Sequential Organ Failure
Assessment (SOFA) score was 12 points, and Acute Physiology and Chronic
Health Evaluation II (APACHE II) score was 30 points. In ICU, the
PaO2 /FiO2 of the patient gradually
deteriorated,
V-V
ECMO and prone position ventilation were implemented on the second day
(Figure 1B ). On the same day after the application of V-V ECMO,
the
echocardiography
revealed that the ejection fraction (EF) of the patient strikingly
dropped to 25%. Once V-V ECMO was initiated, the patient gradually
recovered from the infection and circulatory failure and accordingly
cardiac index and oxygenation were improved. The skin mottling
subsidized on the day 3. On the day 5, the echocardiography indicated
the EF of 55%.
He
was
successfully
weaned from V-V ECMO on day 6 and mechanical ventilation on day 11. And
on the day 15, the EF of the patient was 62%.
Therefore,
the patient was diagnosed as
sepsis
induced cardiomyopathy.
After
detecting of nasopharyngeal swabs and bronchoalveolar lavage samples,
A/H1N1 influenza, influenza B, coronavirus, System Inflammatory Reaction
Syndrome (SIRS), Middle East respiratory syndrome
(MERS)
and other epidemic disease
were
ruled out. And after the admission to the ICU, the patient had a
long-term fever (Figure 3) .
On
the day 22, patient’s pulmonary images findings revealed the recover
(Figure 2B ). He was transferred to a regular room discharged
soon.