SEVERE IMMUNE-MEDIATED DIFFUSE ALVEOLAR HEMORRHAGE IN THE AGE OF COVID-19 AND EXTRACORPOREAL MEMBRANE OXYGENATION

ABSTRACT

SESSION TITLE Pulmonary Manifestations of Infections SESSION TYPE Case Reports PRESENTED ON 10/17/2022 0315 pm - 0415 pm INTRODUCTION: Diffuse alveolar hemorrhage (DAH) due to an undiagnosed autoimmune condition is rare and can be life-threatening. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been described as a viable rescue therapy in severe cases, providing time to establish a diagnosis and begin remission induction therapy (1). We report a patient who presented during the Omicron surge with hypoxemic respiratory failure due to pulmonary hemorrhage ultimately diagnosed with antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) who was supported with VV-ECMO without systemic anticoagulation. CASE PRESENTATION A 46-year-old woman presented with subacute fatigue and two days of cough and brown sputum. She was found to have normocytic anemia (hemoglobin 3.5 g/dL), renal failure (serum creatinine 17.4 µmol/L), and bilateral pulmonary infiltrates on chest roentgenogram. Though vaccinated, nasal molecular testing detected SARS-CoV-2. She was intubated for progressive hypoxic respiratory failure and bronchoalveolar lavage fluid was consistent with DAH. She received empiric antibiotics, remdesivir, and pulse dose intravenous methylprednisolone as well as continuous renal replacement therapy and plasma exchange. Due to refractory hypoxemia she was cannulated for VV-ECMO. Systemic anticoagulation was deferred due to concerns that it may exacerbate her underlying pathology and due to a small subcortical bleed seen on computed tomography of the head. Perinuclear ANCA (titer >11280) was confirmed by immunofluorescence analysis with elevated myeloperoxidase serologies and cyclophosphamide was initiated. Glomeruli with cellular crescent formation consistent with AAV was later identified on renal biopsy. Her course was complicated by recurrent DAH while tapering steroids and an iliac vein thrombus, extracted during decannulation. Her respiratory failure resolved and she was discharged to rehab. DISCUSSION: Traditionally, VV-ECMO obligates systemic anticoagulation to prevent circuit thrombosis, however this may be viewed as a barrier to its use in patients with prohibitive bleeding risk and may contribute to the therapy's overall morbidity. Some institutions have begun to demonstrate the safety of ECMO with low- or prophylactic doses of anticoagulation (2), but this practice remains controversial. Detection of SARS-CoV-2 posed diagnostic and management challenges and its significance to this case remains uncertain. There are many past examples of infectious triggers for both DAH and AAV, and there is emerging evidence for an association between SARS-CoV-2 and ANCA (3). Concerns regarding the risk of B-cell depletion influenced the selection of remission induction therapy. CONCLUSIONS: In the case described, a patient with severe DAH was successfully supported with VV-ECMO. Withholding systemic anticoagulation did not prevent recurrent bleeding and may have contributed to a deep vein thrombosis. Reference #1 Arnold S, Deja M, Nitschke M, Bohnet S, Wallis S, Humrich JY, Riemekasten G, Steinhoff J, Lamprecht P. Extracorporeal membrane oxygenation in ANCA-associated vasculitis. Autoimmun Rev. 2021 Jan;20(1)102702. doi 10.1016/j.autrev.2020.102702. Epub 2020 Nov 11. PMID 33188916. Reference #2 Kurihara C, Walter JM, Karim A, et al. Feasibility of Venovenous Extracorporeal Membrane Oxygenation Without Systemic Anticoagulation. Ann Thorac Surg. 2020;110(4)1209-1215. doi10.1016/j.athoracsur.2020.02.011 Reference #3 Kadkhoda, K., Laurita, K. Antineutrophil cytoplasmic antibodies and their association with clinical outcomes in hospitalized COVID-19 patients. Cell Death Discov. 7, 277 (2021). DISCLOSURES No relevant relationships by Nathaniel Nelson No relevant relationships by Radu Postelnicu no disclosure on file for Antonio Velez;