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Published in: Journal of Cardiothoracic Surgery 1/2024

Open Access 01-12-2024 | ECMO | Case Report

Venovenous extracorporeal membrane oxygenation after cardiac arrest for acute respiratory distress syndrome caused by Legionella: a case report

Authors: John C. Grotberg, Linda Schulte, Erin Schumer, Mary Sullivan, Kunal Kotkar, Mohammad F. Masood, Amit Pawale

Published in: Journal of Cardiothoracic Surgery | Issue 1/2024

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Abstract

Background

Legionella remains underdiagnosed in the intensive care unit and can progress to acute respiratory distress syndrome (ARDS), multiorgan failure and death. In severe cases, venovenous extracorporeal membrane oxygenation (VV-ECMO) allows time for resolution of disease with Legionella-targeted therapy. VV-ECMO outcomes for Legionella are favorable with reported survival greater than 70%. Rapid molecular polymerase chain reaction (PCR) testing of the lower respiratory tract aids in diagnosing Legionella with high sensitivity and specificity. We present a unique case of a patient with a positive COVID-19 test and ARDS who suffered a cardiac arrest. The patient was subsequently cannulated for VV-ECMO, and after lower respiratory tract PCR testing, Legionella was determined to be the cause. She was successfully treated and decannulated from VV-ECMO after eight days.

Case presentation

A 53-year-old female presented with one week of dyspnea and a positive COVID-19 test. She was hypoxemic, hypotensive and had bilateral infiltrates on imaging. She received supplemental oxygen, intravenous fluids, vasopressors, broad spectrum antibiotics, and was transferred to a tertiary care center. She developed progressive hypoxemia and suffered a cardiac arrest, requiring ten minutes of CPR and endotracheal intubation to achieve return of spontaneous circulation. Despite mechanical ventilation and paralysis, she developed refractory hypoxemia and was cannulated for VV-ECMO. Dexamethasone and remdesivir were given for presumed COVID-19. Bronchoscopy with bronchoalveolar lavage (BAL) performed with PCR testing was positive for Legionella pneumophila and negative for COVID-19. Steroids and remdesivir were discontinued and she was treated with azithromycin. Her lung compliance improved, and she was decannulated after eight days on VV-ECMO. She was discharged home on hospital day 16 breathing room air and neurologically intact.

Conclusions

This case illustrates the utility of rapid PCR testing to diagnose Legionella in patients with respiratory failure and the early use of VV-ECMO in patients with refractory hypoxemia secondary to Legionella infection. Moreover, many patients encountered in the ICU may have prior COVID-19 immunity, and though a positive COVID-19 test may be present, further investigation with lower respiratory tract PCR testing may provide alternative diagnoses. Patients with ARDS should undergo Legionella-specific testing, and if Legionella is determined to be the causative organism, early VV-ECMO should be considered in patients with refractory hypoxemia given reported high survival rates.
Literature
2.
go back to reference Barskey A, Lackraj D, Tripathi PS, Cooley L, Lee S, Smith J et al. Legionnaires’ Disease Surveillance Summary Report, United States. Cent Dis Control Prev. 2020. Barskey A, Lackraj D, Tripathi PS, Cooley L, Lee S, Smith J et al. Legionnaires’ Disease Surveillance Summary Report, United States. Cent Dis Control Prev. 2020.
3.
go back to reference El-Ebiary M, Sarmiento X, Torres A, Nogué S, Mesalles E, Bodí M, et al. Prognostic factors of severe Legionella pneumonia requiring admission to ICU. Am J Respir Crit Care Med. 1997;156(5):1467–72.CrossRefPubMed El-Ebiary M, Sarmiento X, Torres A, Nogué S, Mesalles E, Bodí M, et al. Prognostic factors of severe Legionella pneumonia requiring admission to ICU. Am J Respir Crit Care Med. 1997;156(5):1467–72.CrossRefPubMed
4.
go back to reference Falcone M, Russo A, Tiseo G, Cesaretti M, Guarracino F, Menichetti F. Predictors of intensive care unit admission in patients with Legionella pneumonia: role of the time to appropriate antibiotic therapy. Infection. 2021;49(2):321–5.CrossRefPubMed Falcone M, Russo A, Tiseo G, Cesaretti M, Guarracino F, Menichetti F. Predictors of intensive care unit admission in patients with Legionella pneumonia: role of the time to appropriate antibiotic therapy. Infection. 2021;49(2):321–5.CrossRefPubMed
5.
go back to reference Andrea L, Dicpinigaitis PV, Fazzari MJ, Kapoor S. Legionella Pneumonia in the ICU: a Tertiary Care Center Experience over 10 years. Crit Care Explor. 2021;3(8):e0508.CrossRefPubMedPubMedCentral Andrea L, Dicpinigaitis PV, Fazzari MJ, Kapoor S. Legionella Pneumonia in the ICU: a Tertiary Care Center Experience over 10 years. Crit Care Explor. 2021;3(8):e0508.CrossRefPubMedPubMedCentral
6.
go back to reference Müller E, Knoch M, Höltermann WLH. Adult respiratory distress syndrome in legionella pneumonia–successful treatment with extracorporeal CO2 elimination procedures. Anasth Intensivther. 1989;24(3):177–80.CrossRef Müller E, Knoch M, Höltermann WLH. Adult respiratory distress syndrome in legionella pneumonia–successful treatment with extracorporeal CO2 elimination procedures. Anasth Intensivther. 1989;24(3):177–80.CrossRef
7.
go back to reference Nakajima H, Kutsuwada T, Ohdaira T, Saito A, Satoh K, Igarashi K, Suzuki EAM. Extracorporeal membrane oxygenation for acute respiratory failure induced by Legionella pneumoniae. Case report. Nihon Kyobu Shikkan Gakkai Zasshi. 1997;35(12):1363–7.PubMed Nakajima H, Kutsuwada T, Ohdaira T, Saito A, Satoh K, Igarashi K, Suzuki EAM. Extracorporeal membrane oxygenation for acute respiratory failure induced by Legionella pneumoniae. Case report. Nihon Kyobu Shikkan Gakkai Zasshi. 1997;35(12):1363–7.PubMed
8.
go back to reference Naqvi A, Kapoor S, Pradhan M, Dicpinigaitis PV. Outcomes of severe Legionella pneumonia requiring extracorporeal membrane oxygenation (ECMO). J Crit Care. 2021;61:103–6.CrossRefPubMed Naqvi A, Kapoor S, Pradhan M, Dicpinigaitis PV. Outcomes of severe Legionella pneumonia requiring extracorporeal membrane oxygenation (ECMO). J Crit Care. 2021;61:103–6.CrossRefPubMed
9.
go back to reference Dorfman MV, Clark JD, Brogan TV. ECLS for Legionella: all ages welcome in the ELSO Registry. ASAIO J. 2020;66(2):226–9.CrossRefPubMed Dorfman MV, Clark JD, Brogan TV. ECLS for Legionella: all ages welcome in the ELSO Registry. ASAIO J. 2020;66(2):226–9.CrossRefPubMed
10.
go back to reference Descours G, Tellini C, Flamens C, Philit F, Celard M, Etienne J et al. Legionellosis and Lung abscesses: Contribution of Legionella quantitative real-time PCR to an adapted followup. Case Rep Infect Dis. 2013;1–4. Descours G, Tellini C, Flamens C, Philit F, Celard M, Etienne J et al. Legionellosis and Lung abscesses: Contribution of Legionella quantitative real-time PCR to an adapted followup. Case Rep Infect Dis. 2013;1–4.
11.
go back to reference Bryner B, Miskulin J, Smith C, Cooley E, Grams R, Bartlett R, et al. Extracorporeal life support for the adult respiratory distress syndrome due to severe Legionella Pneumonia Benjamin. Perfusion. 2014;29(1):39–43.CrossRefPubMed Bryner B, Miskulin J, Smith C, Cooley E, Grams R, Bartlett R, et al. Extracorporeal life support for the adult respiratory distress syndrome due to severe Legionella Pneumonia Benjamin. Perfusion. 2014;29(1):39–43.CrossRefPubMed
12.
go back to reference Kato H, Murata K, Kashiyama T, Okamoto S, Mikura STM. A case of severe Legionella pneumonia in which survival was achieved without sequelae with the use of extracorporeal membrane oxygenation (ECMO). Kansenshogaku Zasshi. 2013;87(3):375–9.CrossRefPubMed Kato H, Murata K, Kashiyama T, Okamoto S, Mikura STM. A case of severe Legionella pneumonia in which survival was achieved without sequelae with the use of extracorporeal membrane oxygenation (ECMO). Kansenshogaku Zasshi. 2013;87(3):375–9.CrossRefPubMed
13.
go back to reference Uslu BSM. Extracorporeal membrane oxygenation in Legionella pneumonia. Ugeskr Laeger. 2009;171(48):3537–8.PubMed Uslu BSM. Extracorporeal membrane oxygenation in Legionella pneumonia. Ugeskr Laeger. 2009;171(48):3537–8.PubMed
14.
go back to reference Thiara APS, Høyland V, Norum H, Aasmundstad TA, Karlsen HM, Fiane AE, et al. Extracorporeal membrane oxygenation support for 59 days without changing the ECMO circuit: a case of Legionella pneumonia. Perfusion. 2009;24(1):45–7.CrossRefPubMed Thiara APS, Høyland V, Norum H, Aasmundstad TA, Karlsen HM, Fiane AE, et al. Extracorporeal membrane oxygenation support for 59 days without changing the ECMO circuit: a case of Legionella pneumonia. Perfusion. 2009;24(1):45–7.CrossRefPubMed
15.
go back to reference Ichiba S, Jenkins DR, Peek GJ, Brennan KJ, Killer HM, Sosnowski AFR. Severe acute respiratory failure due to legionella pneumonia treated with extracorporeal membrane oxygenation. Clin Infect Dis. 1999;28(3):686–7.CrossRefPubMed Ichiba S, Jenkins DR, Peek GJ, Brennan KJ, Killer HM, Sosnowski AFR. Severe acute respiratory failure due to legionella pneumonia treated with extracorporeal membrane oxygenation. Clin Infect Dis. 1999;28(3):686–7.CrossRefPubMed
16.
go back to reference Gorman D, Green A, Puri N, Dellinger P. Severe ARDS secondary to Legionella Pneumonia requiring VV ECMO in the setting of newly diagnosed hairy cell leukemia. J Investig Med High Impact Case Reports. 2022;10. Gorman D, Green A, Puri N, Dellinger P. Severe ARDS secondary to Legionella Pneumonia requiring VV ECMO in the setting of newly diagnosed hairy cell leukemia. J Investig Med High Impact Case Reports. 2022;10.
17.
go back to reference Jones KM, Dichiacchio L, Deatrick KB, Dolly K, Rea J, Galvagno S, et al. Cardiac arrest prior to initiation of veno-venous extracorporeal membrane oxygenation is not associated with increased in-hospital mortality. ASAIO J. 2020;66(6):E79–281.CrossRefPubMed Jones KM, Dichiacchio L, Deatrick KB, Dolly K, Rea J, Galvagno S, et al. Cardiac arrest prior to initiation of veno-venous extracorporeal membrane oxygenation is not associated with increased in-hospital mortality. ASAIO J. 2020;66(6):E79–281.CrossRefPubMed
18.
go back to reference Allgaier J, Lagu T, Haessler S, Imrey PB, Deshpande A, Guo N, et al. Risk factors, management, and outcomes of Legionella Pneumonia in a large, nationally Representative Sample. Chest. 2021;159(5):1782–92.CrossRefPubMed Allgaier J, Lagu T, Haessler S, Imrey PB, Deshpande A, Guo N, et al. Risk factors, management, and outcomes of Legionella Pneumonia in a large, nationally Representative Sample. Chest. 2021;159(5):1782–92.CrossRefPubMed
19.
go back to reference Turner RB, Rouse S, Elbarbry F, Wanek S, Grover V, Chang E. Azithromycin pharmacokinetics in adults with Acute respiratory distress syndrome undergoing treatment with extracorporeal-membrane oxygenation. Ann Pharmacother. 2016;50(1):72–3.CrossRefPubMed Turner RB, Rouse S, Elbarbry F, Wanek S, Grover V, Chang E. Azithromycin pharmacokinetics in adults with Acute respiratory distress syndrome undergoing treatment with extracorporeal-membrane oxygenation. Ann Pharmacother. 2016;50(1):72–3.CrossRefPubMed
20.
go back to reference Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med. 2019;200(7):E45–67.CrossRefPubMedPubMedCentral Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Am J Respir Crit Care Med. 2019;200(7):E45–67.CrossRefPubMedPubMedCentral
21.
go back to reference Peci A, Winter AL, Gubbay JB. Evaluation and comparison of multiple test methods, including real-time PCR, for Legionella detection in clinical specimens. Front Public Heal. 2016;4(August). Peci A, Winter AL, Gubbay JB. Evaluation and comparison of multiple test methods, including real-time PCR, for Legionella detection in clinical specimens. Front Public Heal. 2016;4(August).
22.
go back to reference Shimada T, Noguchi Y, Jackson JL, Miyashita J, Hayashino Y, Kamiya T, et al. Systematic review and metaanalysis: urinary antigen tests for legionellosis. Chest. 2009;136(6):1576–85.CrossRefPubMed Shimada T, Noguchi Y, Jackson JL, Miyashita J, Hayashino Y, Kamiya T, et al. Systematic review and metaanalysis: urinary antigen tests for legionellosis. Chest. 2009;136(6):1576–85.CrossRefPubMed
23.
go back to reference Cristovam E, Almeida D, Caldeira D, Ferreira JJ, Marques T. Accuracy of diagnostic tests for Legionnaires’ disease: a systematic review. J Med Microbiol. 2017;66(4):485–9.CrossRefPubMed Cristovam E, Almeida D, Caldeira D, Ferreira JJ, Marques T. Accuracy of diagnostic tests for Legionnaires’ disease: a systematic review. J Med Microbiol. 2017;66(4):485–9.CrossRefPubMed
24.
go back to reference Chen DJ, Procop GW, Vogel S, Yen-Lieberman B, Richter SS. Utility of PCR, culture, and Antigen Detection Methods for Diagnosis of Legionellosis. J Clin Microbiol. 2015;53(11):3474–7.CrossRefPubMedPubMedCentral Chen DJ, Procop GW, Vogel S, Yen-Lieberman B, Richter SS. Utility of PCR, culture, and Antigen Detection Methods for Diagnosis of Legionellosis. J Clin Microbiol. 2015;53(11):3474–7.CrossRefPubMedPubMedCentral
Metadata
Title
Venovenous extracorporeal membrane oxygenation after cardiac arrest for acute respiratory distress syndrome caused by Legionella: a case report
Authors
John C. Grotberg
Linda Schulte
Erin Schumer
Mary Sullivan
Kunal Kotkar
Mohammad F. Masood
Amit Pawale
Publication date
01-12-2024
Publisher
BioMed Central
Published in
Journal of Cardiothoracic Surgery / Issue 1/2024
Electronic ISSN: 1749-8090
DOI
https://doi.org/10.1186/s13019-024-02492-6

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