Novel Ph1n1 Viral Cardiomyopathy Requiring Veno-Venous Extracorporeal Membrane Oxygenation
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Novel pH1N1 viral cardiomyopathy requiring veno-venous extracorporeal membrane oxygenation Sujata Subramanian, MD; Jonna D. Clark, MD; Howard E. Jeffries, MD, MBA; D. Michael McMullan, MD Objective: To report a case of pH1N1 viral infection presenting Measurements and Main Results: Discovery of severe dilated as heart failure requiring mechanical extracorporeal life support. cardiomyopathy and respiratory failure. Design: Case report. Conclusions: Patients with pH1N1 may present in profound Setting: Pediatric intensive care unit at a regional children’s hospital. heart failure in addition to respiratory failure. Extracorporeal Patient: Obese 14-yr-old boy who presented with pH1N1-related membrane oxygenation may play an important role in manag- cardiomyopathy and respiratory failure that required extracorporeal ing these complex patients. (Pediatr Crit Care Med 2011; 12: membrane oxygenation. 000–000) Interventions: Extracorporeal membrane oxygenation, echo- KEY WORDS: pH1N1; swine flu; cardiomyopathy; extracorporeal cardiography, high-frequency oscillating ventilation. membrane oxygenation; obesity; children ince the first North American presenting in acute heart failure due to phy. These findings prompted transtho- cases of novel pH1N1 influenza novel viral myocarditis. racic echocardiography, which revealed A were described in April 2009 severe dilated cardiomyopathy with an es- (1), the Centers for Disease Case Summary timated 15% to 20% left ventricular ejec- SControl estimates that, as of December tion fraction. Laboratory studies were 2009, there have been between 39–80 The Institutional Review Board of Se- significant for elevated serum creatinine million cases in the United States. The attle Children’s Hospital approved this (1.3 mg/dL), B-type natriuretic peptide clinical spectrum of novel pH1N1 infec- project and provided exemption to the (1031 pg/mL; normal, Ͻ100 pg/mL), and tion ranges from mild upper respiratory requirement of informed consent. white blood count (6900; 68% neutro- tract symptoms to fatal pneumonia. An A previously healthy, mildly obese phils, 13% bands). In the setting of pos- (body mass index, 28.3 kg/m2) 15-yr-old estimated 8,880 to 16,460 pH1N1-related sible viral myocarditis, the patient was boy presented to his primary careprovider deaths have occurred in the United States empirically treated with intravenous im- with a 2-wk history of fever, productive (2), whereas it is believed that Ͼ14,000 munoglobulin. Direct fluorescent anti- cough with blood-tinged sputum, and deaths have occurred worldwide. Al- body testing of nasopharyngeal fluid did shortness of breath. Review of symptoms though the global number of novel not reveal adenovirus, respiratory syncy- Ͼ was remarkable for abdominal pain with pH1N1 cases is not known, 440,000 lab- tial virus, influenza A or B, parainfluenza coughing, fatigue, and exposure to sib- oratory confirmed cases had been re- viruses, or human metapneumovirus. Ad- ported to the World Health Organization lings with upper respiratory tract infec- tion symptoms. After a brief trial of con- ditionally, coxsackie, enterovirus, cyto- by October 2009 (3). megalovirus, Epstein-Barr virus, parvovi- Although fever, sore throat, and upper servative therapy for presumed viral upper respiratory tract infection, he was rus, and herpes simplex virus were not respiratory tract symptoms are the pre- detected by polymerase chain reaction dominate features of most patients pre- empirically treated with oral amoxicillin (PCR) of airway secretions. senting with novel pH1N1 infection, and clavulanate for the presumptive diag- The patient was then transferred to vomiting and diarrhea have been re- nosis of pneumonia. Worsening symp- Seattle Children’s Hospital for further ported in up to 25% of patients (4). In toms over the next 24 hrs prompted an management and evaluation for cardiac this report, we describe the unusual case emergency department visit, at which transplantation candidacy. On admission of a child with novel pH1N1 infection time he was noted to be in febrile and in profound respiratory distress with sys- to the intensive care unit, he was febrile, temic oxygen saturation of 71%. After a diaphoretic, tachycardic, and mildly hy- failed trial of noninvasive positive pres- potensive. Diffuse hazy airspace opacities From the Divisions of Pediatric Cardiac Surgery were noted on chest radiography (Fig. 1). (MM) and Pediatric Critical Care Medicine (HEJ), Seat- sure ventilation, he underwent endotra- tle Children’s Hospital, Seattle, WA. cheal intubation and required significant A second echocardiogram revealed left The authors have not disclosed any potential con- mechanical ventilatory support with 0.8 ventricle dilation without hypertrophy flicts of interest. FIO2 and 20 cm H2O of positive end- and an estimated body mass index with For information regarding this article, E-mail: an ejection fraction of 18%. Working on a [email protected] expiratory pressure to maintain adequate Copyright © 2011 by the Society of Critical Care oxygenation. The patient was subse- presumed diagnosed of severe respiratory Medicine and the World Federation of Pediatric Inten- quently transferred to a regional medical failure, viral pneumonia, and a viral car- sive and Critical Care Societies center where patchy infiltrates and car- diomyopathy, he was empirically treated DOI: 10.1097/PCC.0b013e3181e327c9 diomegaly were noted by chest radiogra- with ceftriaxone and intravenous immu- Pediatr Crit Care Med 2011 Vol. 12, No. 1 1 findings in the setting of presumed viral myocarditis, a course of high-dose corti- costeroid therapy was initiated. Endo- myocardial biopsy was not performed at that time because of the risks associated with transferring the patient to the cath- eterization suite. The patient’s respiratory and cardiovas- cular status improved over several days, and he was successfully extubated but still required inotropic support. A subsequent echocardiogram demonstrated slightly im- proved cardiac function with moderate left ventricle and left atrium dilation, moderate mitral regurgitation, and estimated ejec- tion fraction of 23%. He underwent diag- nostic cardiac catheterization, which re- vealed normal coronary anatomy, 7 mm Hg transpulmonary gradient, and 34 mm Hg left ventricular end-diastolic pressure. En- domyocardial biopsy obtained at that time revealed myocytolysis and myofibers with Figure 1. Chest radiograph demonstrating diffuse hazy airspace opacity throughout the right lung hypertophic changes. Electron microscopy and in the middle and lower left lung. The transverse diameter of the heart is greater than 1⁄2 the thoracic diameter. demonstrated clearing of the cytoplasm and autophagic vacuoles, suggestive of ba- sophilic degeneration consistent with novel noglobulin. He required intravenous do- Veno-arterial ECMO was considered in pH1N1 viral infection 4 wks before the time pamine, dobutamine, and milrinone infu- the setting of poor cardiac systolic func- of biopsy. In light of ongoing myocardial sions to maintain adequate blood tion; however, the patient had evidence of dysfunction, he is being evaluated for pos- pressure and lidocaine infusion to control adequate perfusion with the assistance of sible cardiac transplantation. frequent premature ventricular contrac- pharmacologic inotropic support. In ad- tions. PCR analysis of nasal washings dition, his serum B-type natriuretic pep- DISCUSSION identified coronavirus and influenza A tide was relatively low (136 pg/mL), and that was subsequently subtyped as novel his serum troponin I was in the normal Between April and December 2009, pH1N1. Enteral oseltamivir and rimanta- range. Veno-venous ECMO flows of ap- 793 patients with confirmed or suspected dine were administered for influenza A. proximately 3.6 L/min were achieved, novel pH1N1 viral infection were evalu- However, poor intestinal absorption providing mixed venous oxygen satura- ated or treated at Seattle Children’s Hos- prompted conversion to intravenous tions of 75% to 80%. He was transitioned pital. Thirty-eight of the 233 hospitalized peramivir, an investigational antiviral to a conventional ventilator (40% FIO2,28 patients with novel pH1N1 infection, in- agent which has received Emergency Use cm H2O peak inspiratory pressure, 15 cluding the patient described in this re- Authorization from the Food and Drug cm H2O positive end-expiratory pressure, port, were admitted to the intensive care Administration for the treatment of novel and 13 cm H2O pressure support). His unit. Seventeen of these patients required pH1N1 influenza (5). Respiratory cul- pulmonary status improved over the next mechanical ventilation, with the average tures did not detect a bacterial source of 5 days. ECMO was weaned and success- length of intensive care unit care being respiratory failure or evidence of bacterial fully discontinued after 6 days of support. 6.1 days. In addition to the patient de- superinfection. Because of the inability to Four days after ECMO decannulation, the scribed in this case report, ECMO support achieve adequate ventilation and oxygen- patient experienced an acute episode of was initially considered for an immuno- ation using conventional ventilation with ventricular tachycardia, which responded suppressed bone marrow transplant re- high pressure at 36 hrs, he was converted to electrical cardioversion and intravenous cipient with aspergillus infection and se- to high-frequency oscillatory ventilation. amiodarone therapy. In addition, the pa- vere pH1N1 respiratory