Legionella Septic Cardiomyopathy Requiring Venoarterial Extracorporeal Membrane Oxygenation Followed by Presumed Complement-Mediated Thrombotic Microangiopathy: A Case Report
Abstract
Background: Legionella pneumophila rarely causes profound myocardial dysfunction and malignant ventricular arrhythmias. Persistent thrombocytopenia and acute kidney injury during recovery may additionally raise concern for thrombotic microangiopathy (TMA), although distinguishing complement-mediated disease from secondary causes in critically ill patients is challenging. Case Presentation: A 64-year-old man presented after five days of fever with recurrent ventricular tachycardia/ventricular fibrillation, cardiac arrest, and refractory shock. Echocardiography demonstrated diffuse biventricular hypokinesia with a left ventricular ejection fraction (LVEF) of 18%, while urgent coronary angiography showed no acute coronary occlusion. Venoarterial extracorporeal membrane oxygenation (VA-ECMO), intra-aortic balloon counterpulsation, and organ support were initiated. Levofloxacin was administered from admission, before sputum sequencing identified L. pneumophila. VA-ECMO was removed after four days. Persistent anaemia and thrombocytopenia with progressive acute kidney injury despite clinical improvement prompted evaluation for thrombotic microangiopathy. ADAMTS13 activity was 92%, soluble C5b-9 was elevated to 648 ng/mL, and schistocytes were not identified. Presumed complement-mediated TMA was treated with four weekly doses of eculizumab, followed by haematological and renal improvement. Sepsis, extracorporeal support, transfusions, and gastrointestinal bleeding confounded…
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