Acute Respiratory Distress Syndrome, Tuberculosis, and Extracorporeal Membrane Oxygenation: A Case Report

Abstract Acute respiratory distress syndrome (ARDS) from tuberculosis is a rare complication of the disease even in geographic regions with high tuberculosis cases and is most encountered in disseminated (miliary) tuberculosis. ARDS from tuberculosis is known to have high mortality especially when requiring mechanical ventilation and is associated with higher mortality than non-tuberculosis causes of ARDS. As with non-tuberculosis cases of ARDS, literature demonstrates case reports of tuberculosis associated with ARDS also being managed successfully with extracorporeal membrane oxygenation (ECMO). A 45-year-old with a past medical history of HIV was transferred from outside facility for VV ECMO consideration given a worsening respiratory status requiring intubation after initial presentation of fever and malaise in the setting of a hospital discharge a few days prior when a left loculated empyema was found requiring chest tube placement and video-assisted thoracoscopic surgery (VATS). On arrival, the patient was cannulated for ECMO on the first day, and while initial labs demonstrated negative cultures (urine, blood, respiratory, acid fast) and a CD4 count of 371 the workup also included an interferon gamma release assay (IGRA) that returned positive for tuberculosis and four drug treatment for tuberculosis was initiated. Initial computed tomography (CT) scan of the chest demonstrated consolidative and ground glass opacities that had worsened from outside CT, as well as pneumothorax on left side where previous VATS occurred. Bronchoscopy was performed, resulting in negative respiratory cultures on bronchoalveolar lavage. The decision was made to biopsy the intercostal and pectoralis muscles of the chest wall at the site of previous chest tube insertion, which returned positive for acid fast cultures. Three weeks into tuberculosis treatment, the patient was noted to have elevated transaminases and pyrazinamide was discontinued. Later blood and respiratory cultures returned positive for Candida albicans. After one month of tuberculosis therapy the repeat CT chest was noticed to have significant improvement, and the patient was able to be decannulated from VV ECMO after 39 days and was discharged with rifampin, isoniazid, ethambutol, and micafungin. This study acts as further literature support for how ECMO can be used to successfully manage ARDS from tuberculosis. Given the high mortality rates of this complication, ECMO can be an important and effective tool to assist with oxygenation while antituberculosis therapy has time to work. This case report also demonstrates an example of navigating antituberculosis therapies given the challenges imposed on the pharmacokinetics of these drugs by the ECMO circuit.