2.2 Case 2
A 10-year-old male was hospitalized due to respiratory system infection
of unknown pathogen. The patient’s clinical state deteriorated quickly
and display respiratory failure as well as capillary leak syndrome and
hypotension. So he was admitted to PICU.
Initial laboratory studies revealed excessive hyperferritinemia (1434
ng/mL), fever up to 40.0℃, low NK cell activity (0.44 %),
hypofibrinogenemia(1.12 g/l), hemoglobinopenia (87 g/L) and thrombopenia
(68 ×109/L) (Table 2). According to these
manifestations, the patient was suspected of HLH and subsequent bone
marrow biopsy supported the diagnosis. In consideration of high PCT
level of 139.3 ng/ml and high IL-6 level of 1549.5 pg/ml, HLH was most
likely triggered by acute bacterial infection. Multiple treatments with
meropene, norepinephrine, IVIG and dexamethasone were initiated.
However, hypotension could not be improved and the patient developed
acute renal failure, CVVHDF (substitute flow 20 mL/kg.h, dialysate flow
20 mL/kg.h and blood flow 3-5mL/kg.min) was started. PE was expected to
be initiated simultaneously. However, we could not get plasma separator
because of COVID-19 epidemic too. So we tried hemoadsorption (HA330-II
perfusion column, Zhuhai Health Sails Biotechnology Co.,Ltd., Zhuhai,
China) combination with CVVHDF again. The anticoagulation was performed
with heaprin sodium. At the meantime, platelets, fibrinogen
prothrombin complex concentrate were infused into the patient to improve
coagulation function. The hemoadsorption was performed once a day and
was continuously done three times. CVVHDF lasted for about 7 days. From
the initiation of hemoadsorption combination with CVVHDF, the dosage of
NE (0.5 µg/kg/min) reduced to 0.3 µg/kg/min after 24 h of treatment and
0.2 µg/kg/min after 72 h later and was weaned off 6 days later (Figure
2). The patient’s IL-6 level decreased to 15.87 pg/mL and PCT decreased
to 0.12 ng/ml after 72 h of therapy (Table 2, Figure 2). On day 11, the
patient was discharged from PICU.