Title: FROM COLD TO CRISIS: A RARE CASE OF ENTEROVIRUS-HUMAN RHINOVIRUS-INDUCED ARDS AND STRESS-INDUCED CARDIOMYOPATHY
Abstract: SESSION TITLE: Critical Care Case Report Posters 59 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Enterovirus-Human-rhinovirus (EV-HRV) is a leading cause of upper respiratory tract infections (URTI), usually presenting as a self-limiting common cold in adults [1]. EV-HRS associated acute respiratory distress syndrome (ARDS) is common in children but rare in adults. We present a case of EV-HRV associated ARDS in an immunocompetent adult, further complicated by stress-induced cardiomyopathy (SICM). CASE PRESENTATION: A 19-year-old woman with no significant medical history presented to the hospital with complaints of fevers, emesis and a maculopapular rash for 5 days. Laboratory results showed leukocytosis and elevated Erythrocyte Sedimentation Rate and C-Reactive Protien. Initial infectious workup identified EV-HRV on nasal swab and evidence of urinary tract infection (UTI). She was initially treated for sepsis secondary to UTI, however she progressively became more hypotensive and hypoxemic requiring supplemental oxygen. Point-of-care cardiac ultrasound showed normal cardiac function. Computed tomography angiogram of the chest excluded pulmonary embolism but revealed extensive bilateral airspace opacities and small bilateral pleural effusions. Despite empiric antibiotics, oxygen requirements continued to rise ultimately leading to intubation and mechanical ventilation. Extensive workup including autoimmune labs (including vasculitic workup), bacterial and fungal cultures, and HIV tests were negative. She underwent bronchoscopy with bronchoalveolar lavage with cultures growing Streptococcus mitis oralis group, which was likely a contaminant. Due to persistent shock, echocardiogram was later repeated, which revealed biventricular dysfunction with a severely reduced left ventricular systolic ejection fraction (EF) of 20-25%. Brain natriuretic peptide was elevated to 41,897pg/ml, with mildly elevated troponin to 0.120ng/ml and no changes on electrocardiogram. A repeat cardiac ultrasound was obtained 5 days after the initial ultrasound, showing marked recovery of left ventricular systolic function with an estimated EF of 55-60%. She was extubated successfully on the 8th day of hospitalization with supportive care and a 7 day course of meropenem. DISCUSSION: EV-HRV infection usually presents as a self-limited URTI in immunocompetent patients. Less frequently, it may lead to manifestations such as asthma exacerbations, meningitis and myocarditis which are associated with higher mortality. Severity of respiratory disease caused by EV-HRV infection is thought to be mediated through the release of pro-inflammatory cytokines such as interleukin (IL)-1, IL-6, and IL-8 [4]. Very few reports of HRV causing ARDS in adults exist, namely one inducing stress cardiomyopathy. One case study demonstrated the use of veno-arterial ECMO for support in a patient with ARDS and SICM that resulted in a poor outcome secondary to other comorbidities [5]. Our patient made a relatively quick recovery with supportive care, likely due to her young age and lack of any prior underlying comorbidities. CONCLUSIONS: EV-HRV infection is notoriously known for causing a relatively mild URTI in the majority of cases, however it can be a rare cause of ARDS in immunocompetent adults leading to multiorgan dysfunction. REFERENCE #1: [1] Heymann PW, Platts-Mills TA, Johnston SL. Role of viral infections, atopy and antiviral immunity in the etiology of wheezing exacerbations among children and young adults. Pediatr Infect Dis J. 2005 Nov;24(11 Suppl):S217-22, discussion S220-1. doi: 10.1097/01.inf.0000188164.33856.f9. PMID: 16378049. REFERENCE #2: Jacobs SE, Lamson DM, St George K, Walsh TJ. Human rhi- noviruses. Clin Microbiol Rev. 2013;26:135-162. REFERENCE #3: Gupta, BS, Shreya; Miessau, MS, Joseph; Pitcher, MD, Harrsion; Baram, MD, Michael; Cavarocchi, MD, Nicholas C.; and Hirose, MD, PhD, Hitoshi, "Left ventricular thrombus found in a patient with ARDS and stress-induced cardiomyopathy requiring veno-arterial ECMO." (2013). Department of Surgery Faculty Papers. Paper 99.https://jdc.jefferson.edu/surgeryfp/99 DISCLOSURES: No disclosure on file for Anirban Basu No relevant relationships by Hadya Elshakh No relevant relationships by Dennis Genin No relevant relationships by Christina Jee Ah Rhee No relevant relationships by Mohamed Sharfi