A 33-year-old female, homeless, with a history of type 2 diabetes, tabaquism and no previous history of lung disease was admitted with a 10-day history of cough, expectoration and progressive dyspnea. SARS-CoV2 infection was ruled out. Chest X-Ray showed bilateral pleural effusion, left tension pneumothorax and tuberculous cavities in the right lung (Fig. 1). A left chest tube (CT) was installed with little improvement in hemodynamics, requiring high-dose vasoactive drugs and IMV. Antibiotic therapy with Vancomycin 1 gr. b.i.d. And Meropenem 1 gr. t.i.d was empirically initiated. Work-up was continued with HIV antibodies testing that was negative. GeneXpert PCR on endotracheal aspirate was positive for TB, with no resistance for rifampicin. Thus, treatment with rifampicin 600 mg/day, isoniazid 300 mg/day, ethambutol 800 mg/day and pyrazinamide 1.5 g/day was initiated. The patient was transferred in this condition to our center to continue her treatment. Upon admission in our hospital, APACHE II score was 17 and PaO2/FiO2 ratio was 65. No other organ disfunction was present at that moment. Due to persistent pneumothorax and air leak, two new CTs were installed upon arrival. The pleural fluid study was compatible with empyema secondary to TB. Despite CTs, she remained unstable with high dose vasoactive drugs (VAD) (norepinephrine 0.8 mcg/kg/min, epinephrine 0,05 mcg/kg/min), with refractory hypoxemia (PaO2/FiO2 = 60) and a lung protective strategy could not be maintained. Bronchopleural fistula hindered IMV as well. In this context, she was connected to femoro-femoral veno-arterial ECMO (VA-ECMO) given her hemodynamics. After ECMO flow initiation, an oxygen saturation of 50 % in the right upper extremity and 100 % in the left upper extremity evidenced a Harlequin Syndrome, so it was converted to veno-arterio-venous (VAV) mode adding a right internal jugular cannula (Fig. 2). She required an embolectomy of the leg 12 hours after ECMO initiation after thrombosis was found in the distal arterial perfusion line. Activated clotting time was adjusted to 200-220 seconds with no further thrombotic issues. On day 4 of VAV-ECMO, VAD were suspended and ECMO was then converted to veno-venous (VV-ECMO), maintaining the right internal jugular for oxygenated blood return and femoral venous cannula for drainage and removing arterial cannulas. Due to persistent pneumothorax a left pleural decortication and fistula repair with an intercostal muscle flap was then successfully done. After 26 days on ECMO, she was weaned from support with good lung re-expansion. A week after a tracheostomy was performed. She was weaned from ventilatory support 2 weeks later. She was discharged home with in-house rehabilitation therapy 20 weeks after admission.
Radiological follow up of the patient. E) Chest computed tomography 6 weeks after left pleural decortication and fistula repair: Complete re-expansion of the right lung, resolution of right pleural effusion with partial left pulmonary re-expansion and persistence of the left hydropneumothorax with decrease of the signs of diffuse bronchiolitis.