Fulminant Pneumococcal Sepsis-induced Cardiomyopathy Managed with Venoarterial Extracorporeal Membrane Oxygenation: A Case Report

Abstract

Sepsis-induced cardiomyopathy is a heterogeneous and potentially reversible form of myocardial dysfunction that may rarely dominate the hemodynamic phenotype of septic shock. Here, we report the case of a 39-year-old man with interstitial lung disease associated with electronic cigarette use who developed fulminant pneumococcal pneumonia complicated by severe hypoxemia, refractory shock, and multiorgan failure. Bronchoalveolar lavage identified Streptococcus pneumoniae , Haemophilus influenzae , rhinovirus, and enterovirus. On transfer to the cardiac intensive care unit, he was mechanically ventilated with (fraction of inspired oxygen = 1.0), and had profound circulatory collapse. This included a mean arterial pressure of 40 mm Hg despite epinephrine, norepinephrine, dobutamine, vasopressin, and angiotensin II. Lactate was 12.5 mmol/L, and transthoracic echocardiography demonstrated critical biventricular dysfunction, left ventricular ejection fraction of 8%, severely reduced left ventricular outflow tract velocity–time integral, severe functional mitral regurgitation, and depressed right ventricular function. Mixed septic-cardiogenic shock with a dominant low-output component was diagnosed. Peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated within 30 min of arrival, with concomitant intra-aortic balloon pump support for left ventricular unloading. Coronary angiography performed after transient ST-segment elevation showed unobstructed coronary arteries. Serial echocardiography demonstrated progressive recovery of myocardial function, with left ventricular ejection fraction improving to 38%–46% by day 9. VA-ECMO and intra-aortic baloon pump were discontinued on day 10, and the patient was extubated on day 12. Acute kidney injury requiring continuous renal replacement therapy resolved, and he was transferred to the pulmonology ward on day 26. This case highlights the potential role of early echocardiography-guided VA-ECMO and adjunctive ventricular unloading in selected patients with fulminant sepsis dominated by profound, reversible myocardial dysfunction.