[Multiple organ failure with several weeks' persistence of ARDS: successful therapy with methylprednisolone]

A 21-year-old female who had developed ileus underwent abdominal surgery for adhesiolysis. Because of postoperative bleeding she required repeated surgical reexploration. Subsequently, the patient developed abdominal sepsis (Enterobacter cloacae) and, on day 11 of mechanical ventilation, severe adult respiratory distress syndrome (ARDS) (Lung injury score 3.5, paO2/FiO2 55 mmHg). Despite clearing the abdominal situation, chest films showed persisting and new pulmonary infiltrates, leucocytosis, fever and purulent bronchial secretion occurring over a period of five weeks. Despite aggressive antibiotic treatment the patient deteriorated further and disease progressed to multiple organ dysfunction syndrome. At the beginning of week six all bacteriological specimens (blood, bronchoalveolar lavage, urine, catheter tips) were negative for potential pathogens. Possible extrapulmonary infection sites were cleared by computed tomography and Tc 99 labeled antigranulocyte antibody scan. Open lung biopsy was performed on day 33 of ARDS and revealed severe diffuse alveolar damage in the fibroproliferative phase of ARDS. On day 37 after ARDS onset, antibiotic treatment was discontinued and methyl-prednisolone (32 mg every 6 hours, 2.5 mg/kg.day) was started. After five days a significant improvement of pulmonary function (lung injury score decreased from 3.5 to 2.5, paO2/FiO2 increased from 82 to > 200 mmHg) and of cardiovascular performance occurred. Corticosteroid treatment was continued for 29 days and was complicated by an episode of pneumonia (Klebsiella pneumoniae) requiring antibiotic therapy. The patient's trachea was successfully extubated on day 80. She was discharged from intensive care unit on day 93 and left hospital three weeks later. We conclude that late ARDS may cause systemic inflammatory response and persisting organ dysfunction without an identifiable source of infection. Corticosteroid therapy might improve fibroproliferative changes of the lung even if instituted weeks after the onset of ARDS.