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.