2.2 Case 2
A 10-year-old male was hospitalized due to respiratory system infection of unknown pathogen. The patient’s clinical state deteriorated quickly and display respiratory failure as well as capillary leak syndrome and hypotension. So he was admitted to PICU.
Initial laboratory studies revealed excessive hyperferritinemia (1434 ng/mL), fever up to 40.0℃, low NK cell activity (0.44 %), hypofibrinogenemia(1.12 g/l), hemoglobinopenia (87 g/L) and thrombopenia (68 ×109/L) (Table 2). According to these manifestations, the patient was suspected of HLH and subsequent bone marrow biopsy supported the diagnosis. In consideration of high PCT level of 139.3 ng/ml and high IL-6 level of 1549.5 pg/ml, HLH was most likely triggered by acute bacterial infection. Multiple treatments with meropene, norepinephrine, IVIG and dexamethasone were initiated. However, hypotension could not be improved and the patient developed acute renal failure, CVVHDF (substitute flow 20 mL/kg.h, dialysate flow 20 mL/kg.h and blood flow 3-5mL/kg.min) was started. PE was expected to be initiated simultaneously. However, we could not get plasma separator because of COVID-19 epidemic too. So we tried hemoadsorption (HA330-II perfusion column, Zhuhai Health Sails Biotechnology Co.,Ltd., Zhuhai, China) combination with CVVHDF again. The anticoagulation was performed with heaprin sodium. At the meantime, platelets, fibrinogen prothrombin complex concentrate were infused into the patient to improve coagulation function. The hemoadsorption was performed once a day and was continuously done three times. CVVHDF lasted for about 7 days. From the initiation of hemoadsorption combination with CVVHDF, the dosage of NE (0.5 µg/kg/min) reduced to 0.3 µg/kg/min after 24 h of treatment and 0.2 µg/kg/min after 72 h later and was weaned off 6 days later (Figure 2). The patient’s IL-6 level decreased to 15.87 pg/mL and PCT decreased to 0.12 ng/ml after 72 h of therapy (Table 2, Figure 2). On day 11, the patient was discharged from PICU.