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Case based discussions
AIP, Jo-1 and ECMO
  1. Anitha Vijayasingam1,
  2. Inmaculada Alcalde2,
  3. Sachin Shah2,
  4. Ben Singer2,
  5. Anthony Bastin2,
  6. Ian Chikanza3,
  7. Jeremy Cordingley2,
  8. Gavin Thomas4
  1. 1 Department of Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
  2. 2 Perioperative Medicine, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
  3. 3 Barts Arthritis Centre, Mile End Hospital, Barts Health NHS Trust, London, UK
  4. 4 Department of Respiratory Medicine, St. Bartholomew’s and Royal London Hospitals, Barts Health NHS Trust, London, UK
  1. Correspondence to Dr Gavin Thomas, Department of Respiratory Medicine, St. Bartholomew’s and Royal London Hospitals, Barts Health NHS Trust, London EC1A 7BE, UK; gavin.thomas{at}bartshealth.nhs.uk

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Case presentation: the trainee

A 56-year-old woman of South Indian origin presented with 2 weeks of cough, fever, malaise and dyspnoea ,with no response to amoxicillin. She was generally well with mild hypertension, type 2 diabetes controlled with metformin, hypothyroidism and vitamin D deficiency. There were no other relevant exposures, previous imaging, lung function or other investigations.

Initial observations: temperature 38.2°C, blood pressure 112/76 mm Hg, RR 24, SpO94% on 3 L/min of O2 via nasal cannulae. Examination of the chest revealed bilateral crackles.

Chest X-ray on admission showed bilateral patchy consolidation to the mid zones (figure 1A).

Figure 1

Radiology on admission, initiation of mechanical ventilation, initiation of ECMO, and discharge.

Initial test results are shown below:

White cell count 8.8×109/L (4–10).

C-reactive protein 141 (<5).

HIV negative.

Throat swab PCR negative for respiratory viruses.

With a working diagnosis of community-acquired pneumonia, treatment was initiated promptly with intravenous amoxicillin/clavulanic acid and clarithromycin, O2 via nasal cannulae, intravenous crystalloids and paracetamol, and the patient was admitted to the acute admissions unit. Despite this, the patient failed to improve. Amoxicillin/clavulanic acid was changed to piperacillin/tazobactam, and she was transferred to the high dependency unit (HDU) 4 days after admission due to increasing O2 requirements. Sputum examination was positive for Candida sp only.

Intensive care assessment

This patient deteriorated despite appropriate medical therapy. She was initially managed on HDU with high flow nasal O2. However, her respiratory failure progressed rapidly, requiring invasive mechanical ventilation 5 days after admission. CT scan of the chest showed features consistent with ARDS (Acute Respiratory Distress Syndrome) (figure 1B).

There was little change over the following 4 days despite treatment with meropenem, clarithromycin and fluconazole. Ten days after admission, on day 5 of mechanical ventilation, gas exchange and lung mechanics rapidly deteriorated with a severe hypoxaemic respiratory acidosis (FiO2 …

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