A 24-year-old woman, born in the United States, weighing 70 kg and 175 cm, with no history of interest, presented to the emergency department with dry cough, precordial discomfort, watery diarrhea and fever.
Examination revealed bilateral crackles and respiratory failure (baseline oxygen saturation 80%).
Chest X-ray showed interstitial infiltrates and bilateral pneumothorax with pneumomediastinum.
Blood tests revealed leukocytosis with left shift (11,700 · 109/L leukocytes, 81% neutrophils), PCR = 15.93 mg/mL and LDH = 1.154 IU/L. Anti-HCV antigen hepatitis virus antigen, respiratory virus antigen virus antigen IgM, and IgM antigen virus antigen virus antigen detection were negative.
With suspicion of severe community-acquired pneumonia, empirical intravenous (iv) treatment was initiated with ceftriaxone 2 g/24 h, levofloxacin 500 mg/12 h for three days, continuing with 500 mg/24 h and hospital therapy.
The patient was admitted to the ICU.
In the first 48 hours the patient presented respiratory deterioration requiring orotracheal intubation and mechanical ventilation. On day +2, the spectrum of amphotericin IV was extended to M. tuberculosis 1200 mg/24 h, linezolid
Diarrhea was limited.
Due to progressive deterioration, 100 mg/12 h iv methylprednisolone 60 mg/8 h iv (due to the possibility of organizing pneumonia or vasculitis) were added on day +6.
The patient presented hemodynamic deterioration and progressive RI attributed to septic shock and nephrotoxicity. A 24-h urine CLcr of 9.4 mL/min (day +6) was observed, with an estimated serum creatinine of 106.5 mL/min at admission.
The aetiological study was extended by autoantibodies to rule out an autoimmune renopulmonary syndrome (anti-neutrophil cytoplasmic antibodies, and to rule out bronchoalveolar antigen determination (also negative), negative bacterial antigen detection (negative bacterial antigen).
Since it was the only microbiological isolation and due to the etiological plausibility, it was oriented as an Adenovirus pneumonia with secondary acute respiratory distress syndrome.
No serotype was identified.
Due to the acute RF of the patient and the negativity of other isolates, liposomal amphotericin B and iv therapy were suspended for renal function improvement was adjusted for the rest of the antibiotic treatment (meropenem 1 g/24 h).
iv. titrated oligoanuria was initiated on day + 11 in the form of CVVHDF due to hemodynamic instability (volume of desired loss of 100-160 mL/h) with corresponding blood flow
Three days later empirical treatment with linezolid and amoxicillin was prescribed.
Lymphopenia, platelet count and progressive anemia accompanied by intraalveolar bleeding were observed after ganciclovir therapy. Hematotoxicity could be enhanced by linezolid treatment.
Therefore, starting treatment with cidofovir was considered, although there was no improvement in renal function.
The contraindication for its use in severe renal failure and the lack of references to its use in CVVHDF in the technical file, a literature search was conducted in Pubmed and Micromedex without finding any reference.
It was finally decided, taking into account the renal function of the patient and the nephrotoxic effect of cidofovir, to institute therapy with reduced dose according to the strategy of Brody et al., in patients undergoing high-flow CLcr 40 mL.
Thus, after obtaining family informed consent, an induction dose of 2.5 mg/kg (175 mg) was administered weekly for 2 weeks and then every 15 days thereafter.
At the time of initiation of treatment (day + 13), the patient had residual diuresis of 300 mL/day.
To prevent nephrotoxicity was performed usual treatment (hydration and probenecid).
Throughout the treatment with fovir, the patient continued to suffer harm attributable and had no adverse effect.
On day + 17, a positive blood culture for coagulase-negative staphylococci was observed, starting treatment with vancomycin 1 g/24 h (CLcr 40 mL/min).
After three treatment doses, plasma concentrations of this antibiotic were monitored, obtaining a minimum concentration of 13 mg/dL, as expected with a CLcr of 40 mL/min, so the same posology was continued.
After four doses of cidofovir, PCR for Adenovirus was negative in day BAL + 27.
A lung biopsy was then performed and no signs suggestive of viral infection were observed, and antiviral treatment was suspended.
Despite the established treatments, the patient presented unfavorable respiratory failure secondary to acute respiratory distress syndrome that required support for Oxygenation with microbiological evolution of the extracorporeal biopsy component, with no further increase (EC) in lung biopsy.
The patient finally died 52 days after admission.
