Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review

Effectiveness and Outcomes of Noninvasive Positive Pressure Ventilation in Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Endotracheal intubation and mechanical ventilation in individuals experiencing acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with several complications. Therefore, utilizing noninvasive positive pressure ventilation (NIPPV) is the suggested initial management for these individuals. The current study was done to assess and compare the clinical and physiological parameters before and after the application of NIPPV and also to evaluate the outcomes of NIPPV.

METHODOLOGY

A prospective observational study was conducted on 50 patients with COPD experiencing acute exacerbations. These patients were treated with NIPPV. Measurements of blood pressure, respiratory rate (RR), heart rate (HR), dyspnea using the modified Borg scale, and arterial blood gas (ABG) parameters (pH, PaCO2, and PaO2) were recorded at baseline, one hour, six hours, 24 hours, and daily until discharge. The study's outcomes included the subjects who successfully underwent NIPPV and failed during NIPPV.

RESULTS

NIPPV effectively reduced the dyspnea score from 7.24 ± 1.58 at baseline to 5.53 ± 1.82 at one hour, 4.11 ± 1.75 at six hours, 2.60 ± 1.03 at 24 hours, and 1.26 ± 0.44 at the time of discharge. Significant improvements were also observed in HR and RR (P < 0.001). When compared to the baseline, the pH level was significantly maintained, PaCO2 was decreased, and PaO2 was increased at various times. Mortality was observed in four patients.

CONCLUSIONS

NIPPV was successful in 42 (84%) patients, with improvements in ABG and pH for early recovery and reduced hospital stay.

Effect of Noninvasive Positive Pressure Ventilation on Prognosis and Blood Gas Level in COPD Patients Complicated with Respiratory Failure

Chronic obstructive pulmonary disease (COPD) is a respiratory disease caused by chronic bronchitis, which seriously threatens the life safety of patients. Noninvasive positive pressure ventilation (NIPPV) has great advantages in its treatment. Here, we explore the effect of NIPPV on prognosis and blood gas level in COPD patients complicated with respiratory failure (RF). A case control study was retrospectively analyzed, where 36 COPD patients with RF were regarded as the regular group to carry on the routine treatment, and 42 patients were assigned to the research group to carry out the routine treatment plus NIPPV. The monofactorial analysis showed that the overall response rate, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC in the research group were higher than those in the regular group, while partial pressure of arterial carbondioxide (PaCO₂), posttreatment endotracheal intubation (EI), length of stay (LOS), tumor necrosis factor (TNF-α), interleukin (IL)-6, IL-1β, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and modified Medical Research Council (mMRC) scores in the research group were lower than those in the regular group. These results indicated that NIPPV can improve the curative effect of emergency medicine patients with RF, improve BG level and PF, reduce inflammation, and facilitate patient's recovery.

Extracorporeal membrane oxygenation rescue for severe pneumocystis pneumonia with the Macklin effect: a case report

Background

Pneumocystis jirovecii pneumonia (PJP) in an immunocompromised host is often associated with the Macklin effect, which can progress to spontaneous pneumomediastinum (SPM), subcutaneous emphysema (SCE), and pneumothorax (PNX). Diagnosing the causative organism of these conditions in non-HIV infected patients and treating hypoxemia while preventing further lung damage can be challenging. This study examines the case of a non-HIV infected male with SPM, SCE, and PNX secondary to severe Pneumocystis jirovecii (PJ) infection.

Case presentation

A 53-year-old male with pure red cell aplasia (PRCA) was admitted with fever, dry cough, and shortness of breath. His respiratory function progressively deteriorated due to the development of SPM, SCE, and PNX, eventually requiring endotracheal intubation and invasive ventilation. As a result of high pressure in his airways occasioned by lung recruitment maneuvers, his pulmonary parameters worsened, necessitating veno-venous (VV) extracorporeal membrane oxygenation (ECMO) therapy. The early initiation of VV-ECMO facilitated ultra-protective lung ventilation and prevented the progression of SPM, SCE, and PNX. Traditional diagnostic assays were unrevealing, whereupon the patient resorted to the metagenomic next-generation sequencing technology for uncovering potential pathogens. Consequently, we detected a significantly higher infection by PJ in the patient’s bronchoscopy lavage fluid. Finally, the patient was successfully treated with appropriate antimicrobials and was decannulated after nine days of ECMO support.

Conclusions

SPM, SCE, and PNX are rare clinical manifestations of PJP. However, they can be considered as poor prognostic factors of the infection. Physicians should, therefore, be alert to the possibility of PJP in immunocompromised patients.

Preliminary Study on the Combination Effect of Clindamycin and Low Dose Trimethoprim-Sulfamethoxazole on Severe Pneumocystis Pneumonia After Renal Transplantation

Objective

Evaluate the effect of the combination of clindamycin with low-dose trimethoprim-sulfamethoxazole (TMP/SMX) regimen on sever Pneumocystis pneumonia (PCP) after renal transplantation.

Method

20 severe PCP patients after renal transplantation were included in this historical-control, retrospective study. A 10 patients were treated with the standard dose of TMP/SMX (T group), the other 10 patients were treated with the combination of clindamycin and low dose TMP/SMX (CT group).

Results

Although there was no significant difference in the hospital survival between the two groups, the CT protocol improved the PaO2/FiO2 ratio more significantly and rapidly after the 6th ICU day (1.51 vs. 0.38, P = 0.014). CT protocol also ameliorated the pulmonary infiltration and the lactate dehydrogenase level more effectively. Moreover, the CT protocol reduced the incidence of pneumomediastinum (0 vs. 50%, P = 0.008), the length of hospital staying (26.5 vs. 39.0 days, P = 0.011) and ICU staying (12.5 vs. 22.5 days, P = 0.008). Furthermore, more thrombocytopenia (9/10 vs. 3/10, P = 0.020) was emerged in the T group than in the CT group. The total adverse reaction rate was much lower in the CT group than in the T group (8/80 vs. 27/80, P < 0.001). Consequently, the dosage of TMP/SMX was reduced in 8 patients, while only 2 patients in the CT group received TMP/SMX decrement (P = 0.023).

Conclusion

The current study proposed that clindamycin combined with low-dose TMP/SMX was more effective and safer the than single use of TMP/SMX for severe PCP patients after renal transplantation (NCT04328688).

Successful lung-protective ventilatory management during the VV-ECMO in a severe COVID-19 pneumonia patient with extensive pneumomediastinum and subcutaneous emphysema: a case report

Background

Ventilatory management of respiratory failure with pneumomediastinum/subcutaneous emphysema is not established. Herein, we report a case of severe COVID-19 pneumonia with extensive pneumomediastinum/subcutaneous emphysema, rescued by thorough lung-protective ventilatory management after applying the VV-ECMO.

Case presentation

A 68-year-old male with no medical history was admitted to a local hospital and diagnosed with COVID-19 pneumonia. His pulmonary parameters worsened during invasive ventilation due to the development of pneumomediastinum/subcutaneous emphysema, and then he was transferred to our hospital. On arrival, we immediately decided to apply VV-ECMO and switch to ultraprotective ventilation. After maintaining the initial ventilation with a neuromuscular blocking agent for 2 days, we gradually increased PEEP while limiting PIP to 25 cmH₂O. The patient was weaned off VV-ECMO on day 10; he was transferred to the medical ward after extubation.

Conclusions

Lung-protective ventilatory management should be performed thoroughly during VV-ECMO in severe COVID-19 pneumonia with pneumomediastinum/subcutaneous emphysema.

Extra Corporeal Membrane Oxygenation in the Treatment of Human Immunodeficiency Virus-Related P. jirovecii Pneumonia

Despite the undeniable complexity one may encounter while managing critically ill patients with human immunodeficiency virus infection (HIV), intensive care unit-related mortality has declined in recent years, not only because of more efficacious antiretroviral therapy (ART) but also due to the advances in critical support. However, the use of extracorporeal membrane oxygenation (ECMO) in these patients remains controversial. We report four cases of HIV-infected patients with Pneumocystis jirovecii pneumonia (PJP) and acute respiratory distress syndrome (ARDS) treated with ECMO support and discuss its indications and possible role in the prevention of barotrauma and ventilator- induced lung injury (VILI). The eventually favorable clinical course of the patients that we present suggests that although immune status is an important aspect in the decision to initiate ECMO support, this technology can provide real benefit in some patients with severe HIV-related refractory ARDS.

A case report of pneumomediastinum in a COVID-19 patient treated with high-flow nasal cannula and review of the literature: Is this a "spontaneous" complication?

Oxygen support with high-flow nasal cannula (HFNC) is gentler than mechanical ventilation and may provide significant benefits, but more studies are needed to investigate the efficacy and safety of different respiratory supports in patients with COVID-19 pneumonia.

Clinical descriptive analysis of severe Pneumocystis jirovecii pneumonia in renal transplantation recipients

Pneumocystis jirovecii (P. jirovecii) pneumonia (PJP) is an opportunistic fungal infection after renal transplantation, which is always severe, difficult to diagnose, combined with multiple complications and have poor prognosis. We retrospectively analyzed clinical data, including risk factors, diagnosis, treatment and complications of seven clinical cases suffered with severe PJP after renal transplantation in our department in 2019. All the seven recipients were routinely prescribed with PJP prophylaxis after renal transplantation, and six of them suffered acute graft rejection before the infection. P. jirovecii sequence was identified in blood or broncho-alveolar lavage fluid (BALF) by the metagenomic next-generation sequencing (mNGS) in all patients. All the patients were improved with the therapy trimethoprim-sulfamethoxazole (TMP-SMX) combined with caspofungin for the PJP treatment, but suffered with complications including renal insufficiency, leukopenia, thrombocytopenia, gastrointestinal bleeding, mediastinalemphysema, pulmonary hemorrhage, and hemophagocytic syndrome and other severe infections. Taken together, mNGS is a powerful tool that could be used to diagnose PJP in renal transplantation recipients. And PJP prophylaxis should be prescribed during and after treatment for acute rejection. TMP-SMX is the first-line and effective drug for PJP treatment, but the complications are always life-threatening and lead to poor prognosis. We should pay attention to these life-threatening complications.

Favourable outcome after prolonged veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for Pneumocystis jirovecii pneumonia in a renal transplant recipient

A 27-year-old man, with a history of renal transplantation, presented with acute kidney failure and Pneumocystis jirovecii pneumonia. The patient developed severe acute respiratory failure and required support by veno-venous extracorporeal membrane oxygenation for a total of 59 days. During this period, the patient had extremely low tidal volumes using a lung protective ventilation strategy and intermittent prone positioning was used to optimise oxygenation. There was full recovery of pulmonary and partial recovery of renal function.

Care of Critically Ill Patients with Human Immunodeficiency Virus

Care of patients with human immunodeficiency virus (HIV) infection in the intensive care unit (ICU) has changed dramatically since the infection was first recognized in the United States in 1981. The purpose of this review is to describe the current important aspects of care of patients with HIV infection in the ICU, with a primary focus on the United States and developed countries. The epidemiology and initial approach to diagnosis and treatment of HIV (including the newest antiretroviral guidelines), common syndromes and their management in the ICU, and typical comorbidities and opportunistic infections of patients with HIV infection are discussed.

Veno-Venous Extracorporeal Membrane Oxygenation for Severe Pneumocystis jirovecii Pneumonia in an Immunocompromised Patient without HIV Infection

Pneumocystis jirovecii pneumonia (PJP) occurs in immunocompromised hosts and is classified as PJP with human immunodeficiency virus (HIV) infection (HIV-PJP) and PJP without HIV infection (non-HIV PJP). Non-HIV PJP rapidly progresses to respiratory failure compared with HIV-PJP possibly due to the difference in immune conditions; namely, the prognosis of non-HIV PJP is worse than that of HIV PJP. However, the diagnosis of non-HIV PJP at the early stage is difficult. Herein, we report a case of severe non-HIV PJP successfully managed with veno-venous extracorporeal membrane oxygenation (V-V ECMO). A 54-year-old woman with neuromyelitis optica was treated with oral corticosteroid, azathioprine, and methotrexate. She admitted to our hospital for fever, dry cough, and dyspnea which developed a week ago. On admission, she required endotracheal intubation and invasive ventilation for hypoxia. A chest computed tomography (CT) scan revealed ground-glass opacity and consolidation in the both lungs. Grocott staining and PCR analysis of bronchoalveolar lavage fluid indicated the presence of fungi and Pneumocystis jirovecii, respectively, whereas serum HIV-antibody was negative. The patient was thus diagnosed with non-HIV PJP and was treated with intravenous pentamidine and corticosteroid pulse therapy for PJP. However, hypoxia was worsened; consequently, V-V ECMO assistance was initiated on day 7. The abnormal chest CT findings and hypoxia were gradually improved. The V-V ECMO support was successfully discontinued on day 14 and mechanical ventilation was discontinued on day 15. V-V ECMO could be a useful choice for respiratory assistance in severe cases of PJP among patients without HIV infection.

A case of broncho-cutaneous fistula secondary to tuberculosis successfully managed with awake veno-venous extracorporeal membrane oxygenation

A broncho-cutaneous fistula (BCF) is a communicating tract between the bronchus and the cutaneous surface of the thoracic wall and can be the primary presenting sign of several disease processes. It has been associated with positive pressure ventilation (PPV), post pneumonectomy, thoracostomy tubes, perforating chest trauma, neoplasia and chronic empyema. We report a case of a 45-year-old immunocompetent man presenting with severe hypercapnic respiratory failure secondary to a BCF as a result of tuberculosis (TB)-related empyema necessitans. Veno-venous extracorporeal membrane oxygenation (VV ECMO) was employed during spontaneous breathing to mitigate the risks of PPV, to facilitate diagnostics and enable targeted treatment. Awake VV ECMO is an effective supportive therapy for complex, destructive lung pathologies with a known reversible aetiology in which PPV would be potentially detrimental.

Use of Extracorporeal Membrane Oxygenation in Pneumocystis Pneumonia of an Infant with AIDS

Pneumocystis pneumonia is a common complication of cellular immunosuppression and may trigger severe pulmonary complications. Rapid onset of acquired immunodeficiency syndrome is possible in infants infected with human immunodeficiency virus (HIV). We report here the case of a 13-week-old girl who was previously healthy presenting with altered immunity and refractory acute respiratory distress syndrome (ARDS) initially attributed to bacterial pneumonia. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated because her condition was poor. An HIV infection was later fortuitously diagnosed after accidental exposure of a nurse to the child's urine. The mother had congenitally transmitted HIV to the child after late (undetected) infection during pregnancy. The lung lesions were finally attributed to Pneumocystis pneumonia. We prescribed combined antiretroviral, antibiotic, and steroid therapy aimed at preventing immune reconstitution inflammatory syndrome. VV-ECMO weaning progressed over 30 days to the time of decannulation, rapidly followed by extubation and hospital discharge. The case highlights the fact that rare curable causes of refractory pediatric ARDS should always be investigated early. VV-ECMO should not be excluded as an ARDS treatment for immunocompromised children.

The use of extracorporeal membrane oxygenation in human immunodeficiency virus-positive patients: a review of a multicenter database

AIM

We chose to evaluate the survival of extracorporeal membrane oxygenation among patients with human immunodeficiency virus in a multicenter registry.

METHODS

Retrospective case review of the Extracorporeal Life Support Organization Registry respiratory failure of all patients with human immunodeficiency virus supported with extracorporeal membrane oxygenation.

RESULTS

A total of 126 patients were included. Survival to discharge was 36%. Eight infants were supported with extracorporeal membrane oxygenation and three (37.5%) survived to discharge. Respiratory extracorporeal membrane oxygenation was the primary indication (78%) with a 39% survival, while cardiac and extracorporeal cardiopulmonary resuscitation indications accounted for 16% and 6% of patients with survivals of 30% and 12.5%, respectively. These differences did not reach significance. There were no significant differences between survivors and non-survivors in demographic data, but non-survivors had significantly more non-human immunodeficiency virus pre-extracorporeal membrane oxygenation infections than survivors. There were no differences in other pre-extracorporeal membrane oxygenation supportive therapies, mechanical ventilator settings, or arterial blood gas results between survivors and non-survivors. The median duration of mechanical ventilation prior to cannulation was 52 (interquartile range: 13-140) hours, while the median duration of the extracorporeal membrane oxygenation exposure was 237 (interquartile range: 125-622) hours. Ventilator settings were significantly lower after 24 hours compared to pre-extracorporeal membrane oxygenation settings. Complications during extracorporeal membrane oxygenation exposure including receipt of renal replacement therapy, inotropic infusions, and cardiopulmonary resuscitation were more common among non-survivors compared to survivors. Central nervous system complications were rare.

CONCLUSION

Survival among patients with human immunodeficiency virus infection who receive extracorporeal membrane oxygenation was less than 40%. Infections before extracorporeal membrane oxygenation cannulation occurred more often in non-survivors. The receipt of renal replacement therapy, inotropic infusions, or cardiopulmonary resuscitation during extracorporeal membrane oxygenation was associated with worse outcome.

Successful Extracorporeal Membrane Oxygenation Treatment in an Acquired Immune Deficiency Syndrome (AIDS) Patient with Acute Respiratory Distress Syndrome (ARDS) Complicating Pneumocystis jirovecii Pneumonia: A Challenging Case

BACKGROUND Patients with HIV infection tend to have poor intensive care unit (ICU) outcomes; however, survival in the modern combination antiretroviral therapy (cART) era has markedly improved, but Pneumocystis jirovecii pneumonia (PJP) still remains a preeminent cause of respiratory failure in AIDS patients. Extracorporeal membrane oxygenation (ECMO) is an adapted cardiopulmonary bypass circuit for temporary life support for patients not responding to conventional treatment. CASE REPORT A 43-year-old male HIV "late presenter" was admitted to our hospital for fever and dyspnea. A chest CT scan revealed bilateral ground-glass opacities. Empiric antibiotic treatment and cART were started. The emergence of ARDS due to PJP dictated urgent veno-venous (VV) ECMO placement. One week later, radiologic findings and respiratory function had improved and the patient was started on a weaning trial from ECMO and removed 12 days after placement. CONCLUSIONS Acute respiratory distress syndrome (ARDS) is a potentially reversible clinical syndrome with a high mortality rate. ECMO is a rescue therapy allowing lung recovery during acute processes and should be considered an adequate treatment option in HIV+ patients with respiratory failure. ECMO should be considered a useful and adequate treatment option in AIDS patients who have a high risk of dying from respiratory failure.

[What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]

Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.

Pneumonectomy in a Child with Multilobar Pneumatocele Secondary to Necrotizing Pneumonia: Case Report and Review of the Literature

Background

Community-acquired pneumonia (CAP) is common within pediatrics and contributes disproportionately to morbidity and mortality. Necrotizing pneumonia is a well-documented complication of CAP. It is thought to be caused by necrosis and liquefaction of consolidated lung and can result in damage to lung parenchyma, including pneumatocele development. Management of necrotizing pneumonia with pneumatocele may include hospitalization, intensive care unit admission, and lengthy antibiotic courses. Severe cases may need invasive procedures.

Case Presentation

We present a case of severe necrotizing pneumonia requiring prolonged venovenous extracorporeal membrane oxygenation (V-V ECMO) with development of persistent pneumatoceles, requiring pneumonectomy while on ECMO support to allow for decannulation and extubation.

Conclusions

In critically ill patients with extensive unilateral necrotizing pneumonia with pneumatocele development, surgical intervention can be considered when attempts to wean ventilation have been unsuccessful. This case provides evidence that V-V ECMO and pneumonectomy is a viable salvage therapy in the most critically unwell children.

The use of extracorporeal membrane oxygenation in HIV-positive patients with severe respiratory failure: a retrospective observational case series

The objective is to describe the outcomes of patients with human immunodeficiency virus (HIV) infection who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure (SRF). The design and setting was a single centre retrospective observational case series, from January 2012 to June 2017, at a tertiary university hospital and regional referral centre for ECMO in the United Kingdom. The participants were all patients referred with SRF and HIV infection. The main outcome measure was patient 90-day survival. Twenty-four patients were referred, of whom nine received ECMO. Six out of nine (67%) of patients were alive at 90 days. Median duration of ECMO was 18 days. There were no identified differences between survivors and non-survivors. ECMO can be used successfully in selected patients with HIV and SRF, including those with poor HIV control and high illness severity. HIV status alone should not exclude patients from treatment with extracorporeal therapy.

Severe acute respiratory distress syndrome in a patient with AIDS successfully treated with veno-venous extracorporeal membrane oxygenation: a case report and literature review

Case

Several successful uses of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome in patients with novel HIV/AIDS infection have been reported; however, the therapeutic keys have not always been discussed.

A 47‐year‐old man was admitted with progressive shortness of breath. He was in respiratory failure with a PaO₂/F_IO₂ ratio of 110.8 requiring intubation. Chest computed tomography showed diffuse ground glass opacities. An HIV infection was suspected, and a diagnosis of acute respiratory distress syndrome was made. Based on clinical indications, treatment for Pneumocystis jirovecii pneumonia and concomitant bacterial infection was started.

Outcome

Despite broad‐spectrum antibiotics, the patient's oxygenation deteriorated, necessitating ECMO. After 19 days of ECMO therapy, the patient was successfully decannulated and was eventually discharged.

Conclusion

In acute respiratory distress syndrome in patients with HIV/AIDS refractory to treatment, ECMO should be considered. Post‐ECMO antiretroviral therapy could improve outcomes.

Extracorporeal Membrane Oxygenation in a 29-Year-Old Man with Pneumocystis jirovecii Respiratory Failure and AIDS

The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been generally beneficial. However, because of various concerns, ECMO has rarely been used in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. We report our successful use of venovenous ECMO in a 29-year-old man who presented with severe respiratory distress secondary to Pneumocystis jirovecii pneumonia associated with undiagnosed infection with the human immunodeficiency virus and acquired immune deficiency syndrome. After highly active antiretroviral therapy was begun, acute immune reconstitution inflammatory syndrome developed. The patient's respiratory condition deteriorated rapidly; he was placed on venovenous ECMO for 19 days and remained intubated thereafter. After a 65-day hospital stay and inpatient pulmonary rehabilitation, he recovered fully. In addition to presenting this case, we review the few previous reports and note the multidisciplinary medical and surgical support necessary to treat similar patients.

Venovenous extracorporeal life support in patients with HIV infection and Pneumocystis jirovecii pneumonia

AIM

As experience with extracorporeal life support (ECLS) increases, indications for its use have expanded to diverse patient populations, including those with HIV infection. Pneumocystis jirovecii pneumonia (PJP) is a particularly devastating complication of HIV infections. The objective of this study was to review ECLS use in HIV-positive patients, with particular emphasis on those with concomitant PJP infection.

METHODS

All patients were treated by the same ECLS team, consisting of an ECLS specialist intensivist, cardiothoracic surgeon and allied medical professionals at three healthcare institutions. The same ECLS protocol was utilized for all patients during the study period. A retrospective review was performed for all HIV-positive patients placed on ECLS from May 2011 to October 2014. Demographic, clinical, ECLS and complication data were reviewed to identify risk factors for death.

RESULTS

A total of 22 HIV-positive patients received ECLS therapy during the study period. All patients were supported with venovenous ECLS and overall survival to hospital discharge was 68%. Survival amongst the PJP positive cohort was 60%. Non-survivors were more likely to require inotropic medications on ECLS (100% non-survivors vs. 46.7% survivors, p=0.022) and had a longer total duration of ECLS (13 days non-survivors vs. 7 days survivors, p=0.011). No difference was observed between PJP-positive and PJP-negative patients with regard to demographic data, complication rates or survival.

CONCLUSION

ECLS is a viable treatment option in carefully selected HIV-positive patients, including those with severe disease as manifested by PJP infection.

HIV-related Pneumocystis jirovecii pneumonia managed with caspofungin and veno-venous extracorporeal membrane oxygenation rescue therapy

Patients with pneumocystis pneumonia have a risk of progressing to acute respiratory failure necessitating admission to intensive care. The case described is of a patient with a newly diagnosed HIV infection presenting with pneumocystis pneumonia. Despite initiating the appropriate pharmacological treatment the patient’s clinical condition deteriorated, and required both rescue pharmacological therapy with echinocandins as well as respiratory support with extracorporeal membrane oxygenation therapy. The patient recovered well on ventilator and circulatory support despite a long weaning process complicated by sequelae common to pneumocystis pneumonia. Following initialisation of antiretroviral therapy and step-down from an intensive care setting, the patient required further prolonged hospital stay for rehabilitation and mental health support before being discharged. This case reviews the novel pharmacological therapies and respiratory support strategies used in cases of pneumocystis pneumonia, including the clinical and psychological sequelae that may follow.

Extracorporeal membrane oxygenation in an HIV-positive man with severe acute respiratory distress syndrome secondary to pneumocystis and cytomegalovirus pneumonia

The management of critically ill human immunodeficiency virus (HIV)-positive patients is challenging; however, intensive care unit-related mortality has declined significantly in recent years. There are 10 case reports in the literature of extracorporeal membrane oxygenation (ECMO) use in HIV-positive patients, of whom seven survived to hospital discharge. We describe a 33-year-old Brazilian man who presented with Pneumocystis jirovecii pneumonia and severe hypoxic respiratory failure. He developed refractory acute respiratory distress syndrome (ARDS) and was commenced on veno-venous ECMO. He was successfully decannulated following 21 days of ECMO and survived to hospital discharge. Despite poor evidence surrounding the use of ECMO in immunocompromised patients, it is evident that ECMO could represent an important rescue therapy in HIV-positive patients with refractory ARDS.

Oxymatrine on Hsp90a expression and apoptosis in a model of lung ischemia-reperfusion injury

The protective effects of oxymatrine (OMT) on apoptosis and heat shock protein 90a (Hsp90a) expression in a rabbit model of lung ischemia-reperfusion injury (LIRI) were investigated. The model of LIRI was established in rabbits and they were randomly divided into two groups: The control group (group C, n=10), and experimental group (further divided into groups E1, n=10; and group E2, n=10), to measure the levels of malondialdehyde (MDA) and superoxide dismutase (SOD) activity in lung tissue homogenates at several time points (T₀, 0 min; T₁, 60 min; T₂, 120 min; T₃, 180 min; and T₄, 240 min), and to measures changes in lung tissue wet/dry weight ratio (W/D), apoptosis index (AI), and Hsp90a expression and organization at T₂, T₃ and T₄. Comparing group C with groups E1 and E2, the levels of SOD activity and MDA were not significantly different at T₀ and T₁ (P>0.05); W/D ratio and AI were significantly higher than in groups E1 and E2 (P<0.05, P<0.01); 120 min after LIR, MDA, W/D ratio, and AI were lower than in groups E1 and E2 (P<0.05, P<0.01). MDA, W/D ratio and AI were lower in E2 than in E1 (P<0.05), and SOD and Hsp90a expression increased (P<0.05). The ultrastructure in group E showed less injury compared with group C. In conclusion, by scavenging oxygen free radicals, OMT can inhibit apoptosis, increase Hsp90a expression, and reduce the injury caused by lung ischemia reperfusion.

Prognostic factors for severe Pneumocystis jiroveci pneumonia of non-HIV patients in intensive care unit: a bicentric retrospective study

BACKGROUND

Pneumocystis jiroveci pneumonia (PJP) in non-HIV patients is still a challenge for intensivists. The aim of our study was to evaluate mortality predictors of PJP patients requiring Intensive care unit (ICU) admission.

METHODS

Retrospectively review medical records of patients with diagnosis of PJP admitted to four ICUs of two academic medical centers from October 2012 to October 2015.

RESULTS

Eighty-two patients were enrolled in the study. Overall hospital mortality was 75.6 %. Compared with survivors, the non-survivors had older age (55 ± 16 vs. 45 ± 17, p = 0.014), higher APACHE II score (20 ± 5 vs. 17 ± 5, p = 0.01), lower white blood cell count (7.68 ± 3.44 vs. 10.48 ± 4.62, p = 0.005), less fever (80.6%vs. 100 %, p = 0.033), more hypotension (58.1 % vs. 20 %, p = 0.003), more pneumomediastinum (29 % vs. 5 %, p = 0.027). Logistic regression analysis demonstrated that age [odds ratio (OR)1.051; 95 % CI 1.007-1.097; p = 0.022], white blood cell count [OR 0.802; 95 % CI 0.670-0.960; p = 0.016], and pneumomediastinum [OR 16.514; 95 % CI 1.330-205.027; p = 0.029] were independently associated with hospital mortality.

CONCLUSIONS

Mortality rate for non-HIV PJP patients requiring ICU admission was still high. Poor prognostic factors included age, white blood cell count and pneumomediastinum.