Introduction: Tuberculosis (TB)-related acute respiratory distress syndrome (ARDS) is a rare complication of pulmonary TB in the United States associated with high mortality. Miliary TB or cavitary TB can lead to TB-related ARDS. Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been described as a bridge to recovery. Available retrospective data indicates a higher survival rate when VV-ECMO support is pursued in miliary TB as opposed to cavitary TB.
Description: A 21-year-old immunocompetent female with no past medical history presented after three months of nonresolving pneumonia in acute hypoxemic respiratory failure requiring mechanical ventilation. Chest imaging showed diffuse micronodules with random pattern. A bronchoalveolar specimen was acid fast bacilli positive and rapid PCR detected Mycobacterium tuberculosis. Her TB isolate showed susceptibility to all first line agents. VV-ECMO was initiated for refractory hypoxemia due to severe ARDS. Progressive fibrocavitary changes characterized her disease process. Her hospital course was complicated by massive hemoptysis requiring therapeutic bronchoscopy, bilateral bronchopleural fistulas despite ultra-lung protective ventilation, and extreme difficulty liberating from deep sedation and neuromuscular blockade. After 44 days on VV-ECMO, her family made the difficult decision to transition to comfort directed measures with discontinuation of ECMO support, after which she expired.
Discussion: Limited data exists to guide decision-making for patients with miliary TB-related ARDS. In an international retrospective cohort of 79 patients with TB-related ARDS supported with VV-ECMO, 90-day survival of 51% is reported. Miliary TB had a more favorable prognosis than that of cavitary TB, with 90-day survival of 81% and 46% respectively. Independent predictors of 90-day mortality included advanced age, drug-resistant TB, and elevated pre-ECMO sequential organ failure assessment score. Our case describes an immunocompetent, and otherwise healthy, young woman who presented with miliary TB-related ARDS and suffered complications due to progressive cavitary disease despite prolonged VV-ECMO support. Even with reported survival in patients with miliary TB-related ARDS, management of complications in this patient population remains a challenge.
