Authors

• Dubravka Šipuš — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-5631-0353
• Luka Perčin — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-0497-6871
• Anica Milinković — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-3456-9540
• Dora Fabijanović — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-2633-3439
• Ivo Planinc — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-0561-6704
• Marijan Pašalić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-3197-2190
• Nina Jakuš — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-7304-1127
• Hrvoje Jurin — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-2599-553X
• Jure Samardžić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-9346-6402
• Boško Skorić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-5979-2346
• Maja Čikeš — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-4772-5549
• Ida Hude Dragičević — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-5527-0647
• Davor Miličić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-9101-1570
• Daniel Lovrić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-5052-6559

Abstract

**Introduction:** Virus associated hemophagocytic syndrome (VAHS) is severe complication of numerous viral infections that is associated with “cytokine storm” and the accumulation of activated T-lymphocytes and macrophages in various organs, frequently resulting in multiorgan failure and death (1, 2). We present a case report of VAHS caused by Influenza A infection. **Case report:** 50-years old, previously healthy male presented to Emergency Department with fever and respiratory failure. Initial arterial blood gases showed global respiratory failure with acidosis (pH 2 9.3 kPa, pO2 8.7 kPa, lactates 13.5 mmol/L, HCO3- unmeasurable). Computed tomography showed left sided pneumonia, and initial laboratory workup showed severe leukopenia, elevated C-reactive protein, and mild renal lesion (**Table 1**). Polymerase Chain Reaction (PCR) was positive for Influenza A, and Streptococcus Pyogenes was isolated from bronchoalveolar lavage. After initial workup patient arrested and cardiopulmonary reanimation (CPR) with intubation was performed. Post-CPR echocardiography showed severely reduced left ventricular systolic function (LVEF 9) | **0.8** (3.4 - 9.7) | | Neutrophiles (x109) | **0.49** (2.06 - 6.49) | | Lymphocytes (x109) | **0.27** (1.19 - 3.35) | | Platelets (x109) | 120 (158 – 424) | | Troponin I (ng/L) | 8.5 (0 - 34.2) | | Urea (mmol/L) | 8.6 (2.8-8.3) | | Creatinine (umol/L) | **138** (60 – 104) | | C reactive protein (mg/L) < 5 | **268.7** (<5) | | Bilirubin (umol/L) | 12 (3 – 20) | | Alanine-aminotransferase (U/L) | 24 (12 – 48) | | D-Dimers (mg/L) | 4.35 (0-0.50) | FIGURE 1. Imaging methods after admission: A) Chest X-ray after VA ECMO placement showing bilateral extensive confluent, homogeneous infiltrates of the lung parenchyma; B) Computed tomography showing extensive zones of consolidation in the lower lobes of the lungs and large zone of destruction of left lower lung lobe; C) Echocardiography (subcostal view) showing thrombus formation in the left ventricle. **Conclusion:** VAHS is one of rare and potentially lethal complications of Influenza A which can lead to multiorgan failure that can require mechanical circulatory support. Echocardiography plays crucial role in diagnostics and management of critical ill patients.

Keywords

hemophagocytic syndrome, influenza A, multiorgan failure

DOI

Literature

1. Hayden A, Park S, Giustini D, Lee AY, Chen LY. Hemophagocytic syndromes (HPSs) including hemophagocytic lymphohistiocytosis (HLH) in adults: A systematic scoping review. Blood Rev. 2016 November;30(6):411–20. https://doi.org/10.1016/j.blre.2016.05.001
2. Beutel G, Wiesner O, Eder M, Hafer C, Schneider AS, Kielstein JT, et al. Virus-associated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection. Crit Care. 2011;15(2):R80. https://doi.org/10.1186/cc10073