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Leptospirosis is an infectious disease that is characterized by vasculitis, the underlying cause of the clinical manifestations being capillary endothelial cell injury. Leptospirosis can involve multiple organ systems and cause renal tubular dysfunction, hepatic dysfunction, myocarditis, and alveolar hemorrhage.(1) Pulmonary involvement can manifest as acute respiratory distress syndrome (ARDS), in which the need for mechanical ventilation is associated with a mortality rate of 30-60%.(2) The controversy regarding the various alveolar recruitment maneuvers (ARMs) and their role in patients with ARDS motivated us to describe the case of a patient with ARDS secondary to leptospirosis, in whom a CT-guided ARM with sustained high pressure was successfully performed.(3,4) A previously healthy 21-year-old male patient was admitted to the emergency room with a one-week history of headache, myalgia, and fever (39 °C), as well as with a two-day history of progressive dyspnea. The patient developed respiratory failure requiring orotracheal intubation and ventilatory support, being transferred to our hospital. He reported occupational exposure to soil during gardening activities. The patient presented with poor general health status, being on mechanical ventilation and hemodynamically stable without the use of vasoactive drugs. He also presented with right conjunctival hemorrhagic suffusion. The initial laboratory test results were as follows: • hematocrit, 29.8% • hemoglobin, 11 g/dL • leukocytes, 14,000 cells/mm3 (12,082 segmented neutrophils and 1,040 lymphocytes) • platelets, 145,000 cells/mm3 • C-reactive protein, 95.1 mg/L • sodium, 143 mEq/L • potassium, 3.1 mEq/L • urea, 38 mg/dL • creatinine, 1.2 mg/dL • indirect bilirubin, 0.66 mg/dL • direct bilirubin, 1.65 mg/dL • prothrombin time, 1.19 • activated partial thromboplastin time, 111% • albumin, 2.5 g/dL • glutamic-oxaloacetic transaminase, 96 U/L • glutamic-pyruvic transaminase, 43 U/L • lactate dehydrogenase, 883 U/L • creatine phosphokinase, 995 U/L • urinalysis, normal Arterial blood gas analysis results were as follows: pH, 7.34; PaO2, 79.8 mmHg; PaCO2, 55.3 mmHg; bicarbonate, 29.2 mEq/L; SaO2, 95.1%; FiO2, 0.8; and PaO2/FiO2 ratio, 99. A chest X-ray revealed bilateral homogeneous diffuse opacity. An echocardiogram revealed normal cardiac function. The patient was started on antibiotic therapy with ceftriaxone, clarithromycin, and oxacillin for severe community-acquired pneumonia. Because the patient was suspected of having influenza A (H1N1) infection, he was started on antiviral treatment with oseltamivir. Because the patient presented with refractory hypoxemia, a CT scan was taken. During the procedure, an ARM was performed. The patient remained properly sedated and was hemodynamically stable. He was submitted to pressure-controlled ventilation (PCV), as follows: RR, 15 breaths/min; inspiratory time, 2 s; inhalation/exhalation ratio, 1:1; FiO2, 1; and pressure, 15 cmH2O above a positive end-expiratory pressure (PEEP) of 25 cmH2O for 2 min. The functional and radiological responses were evaluated immediately before the ARM Protective ventilation and alveolar recruitment maneuver in a patient with leptospirosis-induced acute respiratory distress syndrome

Estratégia ventilatória protetora e manobra de recrutamento alveolar em paciente com síndrome do desconforto respiratório agudo por leptospirose