An Early Aggressive Strategy for the Treatment of Hanta Virus Cardiopulmonary Syndrome: A Perspective From an Extracorporeal Membrane Oxygenation Center

TO THE EDITOR—We received a 47year-old man in cardiopulmonary distress. Two weeks before admission, the patient had experienced fevers, myalgias, anorexia, and fatigue. He went to a local emergency department where he received antibiotics and was discharged with presumed community-acquired pneumonia. Four hours later, he returned with worsening dyspnea in hypoxemic respiratory failure. Chest radiograph was reported as multifocal pneumonia. Intravenous antibiotics were initiated and he was transferred to our hospital. Three weeks earlier, he had gone fishing in Port Lavaca, Texas, and stayed in a cabin infested with rat feces. The rest of his social and family history was unremarkable. On initial presentation, noninvasive ventilation was converted to intubation and mechanical ventilation for worsening hypoxemia. His exam showed fever with a temperature of 39.2°C, blood pressure of 91/63 mm Hg, and tachycardia. Hypoxemia persisted despite support with 100% fraction of inspired oxygen and high positive end expiratory pressure. Aside from diffuse lung crackles, the rest of his exam was negative. His initial chest radiograph had bilateral alveolar opacities. Blood gas revealed a PaO2/FiO2 ratio <100, consistent with severe acute respiratory distress syndrome (ARDS). His laboratory tests showed a white blood count of 49 000 cells/μL, acute renal failure with a creatinine level of 3.8 mg/dL, and severe lactic acidosis with a serum lactate level of 47 mg/dL. Bedside cardiac echocardiography demonstrated poor left ventricle contractility. Because of combined hemodynamic and pulmonary failure with epidemiological data concerning for Hanta virus exposure, the patient underwent early venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. Hanta virus studies were sent to the Centers for Disease Control and Prevention, later coming back positive. We provided full hemodynamic support and lung “rest” ventilation, and utilized continuous renal replacement therapy to limit volume overload. His systolic function, oxygenation, and radiographic findings rapidly improved (Figure 1). He was successfully