Capillary leak syndrome:A rare cause of acute respiratory distress syndrome

TO THE EDlTOR

We read with interest the case report by Nong

[1],describing a rare case of severe capillary leak syndrome(CLS)in organophosphorus(OP)poisoning and the use of veno-venous extracorporeal membrane oxygenation(V-V ECMO)for the treatment.An extensive literature review on PubMed did not reveal any other reported cases of CLS in OP poisoning.It was a commendable effort on the part of the treating team to treat a rare case of CLS.This letter is intended to discuss and address the dilemmas in the case report by Nong

[1].

21.Keep tight hold of my fur, and then there is no danger: The daughter is encouraged to literally67 cling to her spouse68 who will protect her in her journey away from her childhood and into adulthood.Return to place in story.

The antimuscarinic agent atropine,oximes(to reactivate acetylcholinesterase),neuroprotective drugs,and intensive care remain the mainstay of treatment for OP poisoning.Haemodialysis with hemoperfusion was used for detoxification in the reported patient.This has shown promising results in treating patients with OP poisoning,preventing multi-organ dysfunction and improving the prognosis of patients[2].However,the purpose of phencyclidine hydrochloride administration in the case study needs clarification.

The patient further developed acute respiratory distress syndrome(ARDS)with intra-abdominal hypertension(IAH)due to severe CLS,and V-V ECMO was initiated in view of refractory hypoxemia.Prone ventilation could be a promising option before initiating ECMO as it may improve oxygenation in ARDS,even in the presence of IAH,by suspending and off-loading the abdomen[3].A patient with ARDS and IAH has been reported to be successfully proned after suspension and abdominal unloading,with a progressive reduction of IAP from 24 mmHg to 14 mmHg,and reduction of peak airway pressures from 44 cm H

O to 22 cm H

O[4].However,further studies are required to prove the benefit of prone positioning in patients with IAH and severe hypoxemia.

In the case report,the patient was managed with judicious use of crystalloids,colloids,and plasma[1].The type of colloid used needs a mention.Substances with a molecular weight of less than 200000 Da can pass through the leaky capillaries into the interstitial space in CLS,as would albumin with a molecular weight of 69000 Da[5].A meta-analysis comparing crystalloids with colloids in intensive care settings concluded that among different colloids(dextrans,albumin,gelatins,and hydroxyethyl starch),starch was associated with an increased mortality[6].Nevertheless,in the event of refractory shock in CLS,the potential benefits of administration of high molecular weight colloids like dextrans and starch may outweigh the risks of renal dysfunction and mortality[5].However,further research is warranted to determine the optimal fluid therapy.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

Juneja D and Kataria S contributed equally to this work;Juneja D performed the literature search,and designed and edited the manuscript;Kataria S wrote and revised the manuscript;all the authors have read and approved the final manuscript.

India

FOOTNOTES

ECMO is an attractive choice as a bridge to spontaneous recovery of CLS in patients with refractory shock or hypoxemia[9].The use of V-V ECMO and veno-arterial ECMO(V-A ECMO)is dependent on the hemodynamic profile,with patients with fluid overload or intact perfusion needing V-V ECMO and patients with fulminant hypovolemic shock requiring V-A ECMO.ECMO support should be continued during the post leak phase to avoid pulmonary overload,and the risk-benefit ratio should be considered as an increase in inflammatory mediators in some patients can worsen the clinical condition.In patients with acute intoxication having refractory hypoxemia or refractory cardiogenic shock,V-V or V-A ECMO should be considered,respectively,and in institutions that deliver effective extracorporeal cardiopulmonary resuscitation,it can also be considered in patients during a cardiac arrest[10].

The authors declare that they have no conflict of interest to disclose.

In addition to fluid therapy,steroids and intravenous immunoglobulin(IVIG)have demonstrated efficacy in a few cases of severe CLS.Steroids,by countering the inflammatory triggers of CLS can reduce the severity of capillary leakage.Promising results have been shown when IV methylprednisolone was used at a dose of 1-1.5 mg/kg,until resolution of signs and symptoms or for 2 d,and switched to oral prednisolone 40 mg once daily and then tapered off[5,7].IVIG therapy,by its antiinflammatory and anti-idiotypic effects,has shown dramatic improvement when used at a dose of 2 g/kg over 2-4 d,with some patients requiring a maintenance dose of 0.4-2 g/kg every month[5,8].Nevertheless,its use should be considered cautiously in light of its potential nephrotoxicity,especially in patients with compartment syndrome.Although most of the above evidence of steroids and IVIG use is from chemotherapeutic drugs induced CLS and Clarkson disease,both of these could be compelling therapeutic options in patients refractory to the standard therapy in other causes of CLS.However,both their optimal doses and duration remain undetermined and warrant further research.

Without a doubt, it was the best wedding gift I received. One I would never forget. My father showered me with his gifts every day of his life. How did I get so lucky?

The blessing11 to Karen and I was twofold. In addition to ending years of confusion and estrangement12（，） , we learned to share the joy of being the proud daughters of two extraordinary fathers.

A while ago, Seanko developed a deep-learning algorithm that captioned images and videos with impressive accuracy. The problem was that her captioning application had developed a bias toward certain types of decisions, a problem that is common in deep-learning algorithms. For instance, in cooking videos, it often captioned kitchen workers as women ¡ª even when they were men. On the other han

Deven Juneja 0000-0002-8841-5678;Sahil Kataria 0000-0002-0756-4154.

Guo XR

Wang TQ

Qi WW

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