(564) Successful Treatment of Cardiopulmonary Collapse With ECMO in a Severe Hantavirus Infection

Introduction: In the spring of 1993, a cluster of 24 cases of an unknown and deadly virus in the Four Corners region garnered the attention of the Center for Disease Control. Otherwise healthy people died of pulmonary edema and cardiovascular collapse just days after initial presentation for flu-like symptoms. This outbreak led to the identification of a novel hantavirus causing Hantavirus Cardiopulmonary Syndrome (HCPS) . Due to its proximity to areas with high rates of hantavirus transmission, the University of New Mexico developed the use of extracorporeal membrane oxygenation (ECMO) for HCPS. ECMO support reduces mortality from HCPS from nearly 100% to 33%.

Description: A middle-aged woman presented to a community hospital in western New Mexico complaining of fever and body aches. She was discharged, but four days later, she returned with severe shortness of breath. The patient was hypoxemic, tachypneic, and febrile. Providers began aggressive intravenous fluid rehydration for sepsis of unknown source. Soon after that, the patient required non-invasive ventilation and high doses of vasopressors, prompting transfer to a higher level of care. Patient’s initial workup was notable for hemoconcentration, thrombocytopenia, bilateral pulmonary effusions, and acute kidney injury, raising concern for HCPS.

Severe weather delayed the patient’s transfer. On arrival, the patient was hypotensive, encephalopathic, and hypoxemic on noninvasive ventilation. Given the patient’s tenuous status, providers obtained catheter access for venoarterial (VA) ECMO. Following confirmation of hantavirus diagnosis by IgM, within 30 minutes of arrival providers decided to cannulate the patient awake given her extremely labile and tenuous hemodynamic status. After being stabilized on VA ECMO, the patient was then intubated. The patient was decannulated on hospital-day three and discharged to rehab on hospital-day twelve.

Discussion: This case demonstrates the morbidity of delayed diagnosis of hantavirus. Consideration of acute hantavirus infection early in the differential diagnosis can prevent iatrogenic volume overload and slow the transition to HCPS. This case demonstrates the need for early preparation for ECMO in these patients who are prone to rapid decompensation and progression to respiratory and cardiac arrest.