CHEST Guidelines-A-57-Year-Old-Man-With-COVID-19-Pneumonia-Who-Requ

A-57-Year-Old-Man-With-COVID-19-Pneumonia-Who-Requ

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This case study outlines the journey of a 57-year-old man with COVID-19 pneumonia who required venovenous extracorporeal membrane oxygenation (ECMO) due to hypoxemic respiratory failure. During his hospitalization, the patient experienced a dramatic increase in white blood cell (WBC) count, rising from 17,500 to 47,000 cells/mL over ECMO days 13 to 17, and developed fluid-refractory shock necessitating multiple vasopressors and stress-dose hydrocortisone. Despite being afebrile, he was administered broad-spectrum antimicrobials, including antifungal and anthelminthic therapies. <br /><br />The physical examination presented several concerning findings: the patient was sedated, immobilized, with a rapid heart rate of 146 bpm and oxygen saturation at 91%. He displayed minimal breath sounds and received a low tidal volume during ventilation. Diagnostic evaluations, including blood, urine cultures, bronchoalveolar lavage (BAL), and imaging studies, did not reveal infections. Notable lab values showed undetectable anti-Xa levels, elevated D-dimer, and liver enzymes. <br /><br />Ultimately, a CT scan identified a retroperitoneal hemorrhage, which was unmasked as the underlying cause of the leukemoid reaction and rapid WBC elevation. Originating from acute blood loss anemia due to the hemorrhage, the leukemoid reaction prompted the stress response marked by elevated WBCs. The patient received transfusions including packed RBCs, fresh frozen plasma, and platelets, leading to partial resolution of leukocytosis.<br /><br />Despite interventions, the patient’s respiratory function did not improve, and his family opted to withdraw life-sustaining treatments on ECMO day 23. The case highlights the diagnostic challenges of leukemoid reactions in ECMO patients, exacerbated by potential coagulopathy and the masking of symptoms in critically ill individuals, and underscores the importance of proactive imaging and high clinical suspicion.

Keywords

COVID-19 pneumonia

venovenous ECMO

hypoxemic respiratory failure

leukemoid reaction

retroperitoneal hemorrhage

fluid-refractory shock

broad-spectrum antimicrobials

acute blood loss anemia

diagnostic challenges

coagulopathy