Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

06 January 2022: Articles  Japan

A 48-Year-Old Previously Healthy Man Presenting with Acute Respiratory Distress Syndrome (ARDS), Negative Tests for SARS-CoV-2, and Positive Serology for Parainfluenza Virus Type 3 (PIV-3)

Challenging differential diagnosis, Rare disease

Ryuichiro Kakizaki ORCID logo1ABDEF*, Ryutaro Tojo1AB, Naofumi Bunya ORCID logo1BD, Hirotoshi Mizuno1BD, Shuji Uemura1D, Eichi Narimatsu1DE

DOI: 10.12659/AJCR.934362

Am J Case Rep 2022; 23:e934362

0 Comments

Abstract

BACKGROUND: Human parainfluenza viruses (PIVs) belong to the Paramyxoviridae family. PIVs cause lower respiratory tract infections in children and the elderly. In addition, severe pneumonia due to PIVs has been reported in immunocompromised adults. However, no reports have described PIV infections leading to acute respiratory distress syndrome (ARDS) in immunocompetent hosts.

CASE REPORT: A 48-year-old otherwise healthy man was transported to our hospital due to worsening dyspnea. On arrival, strong effortful breathing was observed and results of arterial blood gas analysis revealed severe hypoxia. On the basis of the clinical presentation, we intubated the patient for mechanical ventilation. However, mechanical ventilation provided inadequate oxygenation. Finally, veno-venous extracorporeal membrane oxygenation was initiated. Pneumonia was considered to be a cause of the ARDS, based on the patient’s history and blood examination. Repeated reverse transcription-polymerase chain reaction tests for the novel coronavirus were performed, and endotracheal aspirate specimens were cultured for bacteria and fungus; however, the results were all negative. On day 2, the PIV-3-specific antibody titer was elevated. Two weeks later, the PIV-3-specific antibody titer had increased 4-fold. On the basis of these results, we diagnosed pneumonia induced by PIV-3 infection.

CONCLUSIONS: ARDS can occur because of severe pneumonia induced by PIV-3. In cases of unexplained severe pneumonia or ARDS, PIV infection should be included in the differential diagnosis.

Keywords: Extracorporeal Membrane Oxygenation, Paramyxoviridae, Pneumonia, Viral

Background

Acute respiratory distress syndrome (ARDS) is a life-threatening condition defined by the association of bilateral infiltrates and hypoxemia due to a variety of pulmonary and non-pulmonary insults [1]. Pneumonia is the leading cause of ARDS; thus, accurate identification of the pathogen responsible for infection is necessary [2].

Human parainfluenza viruses (PIVs) belong to the Paramyxoviridae family. PIVs are enveloped RNA viruses [3]. PIVs cause upper respiratory tract infections in children and adults and lower respiratory tract infections in children younger than 5 years and elderly or immunocompromised adults. PIVs infections exhibit a distinctly bimodal pattern of age distribution [4]. Severe pneumonia in immunocompromised adults has been reported, particularly in patients with hematologic malignancies and hematopoietic stem cell transplant recipients [5,6]. However, no reports have described PIV infections leading to ARDS in immunocompetent hosts. Here, we report a case of ARDS induced by PIV that was successfully resuscitated using extracorporeal membrane oxygenation (ECMO) in a healthy young adult.

Case Report

A 48-year-old healthy man with no previous medical history (body mass index, 21.1) had been experiencing cold symptoms for 2 weeks and was treated by a nearby physician. The patient was transported to our hospital due to worsening dyspnea.

On arrival, his initial vital signs were as follows: Glasgow Coma Scale score, 15 (E4V5M6); respiratory rate, 32/min; percutaneous oxygen saturation, 85% under assisted ventilation with bag valve mask; heart rate, 120/min; blood pressure, 108/60 mmHg; and body temperature, 38°C. Labored breathing was observed, and arterial blood gas analysis revealed severe hypoxia (Table 1). On the basis of the clinical presentation, we intubated the patient for mechanical ventilation. However, mechanical ventilation provided inadequate oxygenation. The PaO2/FiO2 ratio was 81.8 and did not improve. Finally, venovenous ECMO was initiated. A chest computed tomography (CT) showed bilateral mixed ground-glass opacity (GGO) and consolidation (Figures 1, 2).

Pneumonia was considered to be the cause of the ARDS, based on the patient’s history and blood tests. Administration of broad-spectrum antimicrobial agents was initiated while a search for the etiology of pathogens was conducted. At this time, the novel coronavirus (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) was beginning to spread in Japan, and a few ARDS cases due to the novel coronavirus had occurred. Therefore, pneumonia caused by the novel coronavirus was suspected. Reverse transcription-polymerase chain reaction (RT-PCR) test was repeated 3 times; however, the RT-PCR tests using a nasopharyngeal swab, sputum, and bronchoalveolar lavage fluid were all negative. Blood, endotracheal aspirate, and bronchoalveolar lavage fluid specimen cultures were negative for bacteria and fungus. Tests for bacterial and viral antigens that cause pneumonia were also negative (Table 2).

On day 2, the PIV antibody titer in the serum specimen was measured, and the PIV-3-specific antibody titer was elevated. Two weeks later, the PIV-3-specific antibody titer had increased 4-fold (Table 3). On the basis of the elevated antibody titers in paired serum specimens, we diagnosed pneumonia induced by PIV-3 infection.

On day 9, the patient went into cardiac arrest when we were changing the ECMO circuit. He underwent chest compressions and developed bilateral hemopneumothorax; therefore, thoracic drainage and a partial lung resection were performed. He had secondary refractory pneumothorax, which resulted in prolonged ECMO treatment. The patient’s respiratory condition gradually improved, and the GGO and consolidation on chest CT disappeared (Figure 3). Finally, the patient was taken off of ECMO on day 52 and transferred to another hospital for continued rehabilitation on day 67, without neurological deficits.

Discussion

This is the first report of severe pneumonia progressing to ARDS caused by PIV-3 in an otherwise healthy adult. ARDS caused by pneumonia may be reversible; therefore, microbiological examinations for a wide range of pathogens are important for the initial assessment of patients with ARDS [4]. PIVs cause 22–29% of community-acquired pneumonia, with influenza viruses and rhinoviruses being the most common [7–9]. PIV infections account for 1–15% of respiratory illnesses in adults, with infrequent reports of pneumonia in young adults and a higher risk for severe disease in frail older adults [10]. There are 4 types (1 through 4) and 2 subtypes (4a and 4b) of PIVs. The prevalence of each serotype attributed to infection varies with time, but most studies show that PIV-3 is the most common cause of clinically significant infection [11]. Acquisition of PIV-3 usually occurs early in life, with 50% and 92% of children infected by 1 and 3 years of age, respectively. PIV-3 is isolated predominantly from patients under 5 years of age [4]. Severe pneumonia due to PIV-3 also occurs in hematopoietic stem cell transplant or lung transplant recipients [5,6,12]. However, no reports have described severe pneumonia caused by PIV-3 in immunocompetent hosts. In the present case, there was no co-infection with any virus other than PIV-3. We did not measure the levels of cytokines and could not assess the immune response. However, 50% hemolytic complement activity (CH50) was activated, and we considered that the immune response was normal. Our case suggests that PIV-3 can be the cause of severe pneumonia and ARDS of unknown origin.

The clinical presentation of PIV infection in adults, including cough, rhinorrhea, and sore throat, is indistinguishable from other respiratory illnesses [4]. Typical chest CT findings for PIV pneumonia are multifocal patchy consolidation with GGO and centrilobular nodules with bronchial wall thickening [13]. In this case, the patient already had severe respiratory failure upon arrival at the hospital, and chest CT showed widespread GGO and consolidation. Thus, the cause of ARDS was difficult to diagnose.

Infection with PIVs can be confirmed by: 1) direct detection of the viral genome using PCR, 2) direct detection of viral antigens in respiratory secretions (collected within 1 week of symptom onset) using immunofluorescence or enzyme immunoassays, 3) isolation and identification of the virus in cell culture, or 4) demonstration of a significant rise in PIV-specific IgG antibodies between appropriately collected paired serum specimens or specific IgM antibodies in a single serum specimen [14]. When this case occurred, a worldwide pandemic of the novel coronavirus infection had started and was beginning to spread in Japan. Almost all of the PCR assays were used to test for novel coronavirus infections and were not available for the diagnosis of PIVs. Thus, we used the serologic diagnosis to show a significant rise in IgG antibodies between paired serum specimens. If the PCR test had been used to diagnose PIV, the diagnosis could have been made more promptly.

Conclusions

ARDS can occur because of severe pneumonia induced by PIV-3 without viral co-infection. Our experience suggests that PIV infection should be included in the differential diagnosis in cases of unexplained severe pneumonia or ARDS in immunocompetent hosts.

References:

1.. Fan E, Brodie D, Slutsky AS, Acute respiratory distress syndrome: Advances in diagnosis and treatment: JAMA, 2018; 319; 698-710

2.. Papazian L, Calfee CS, Chiumello D, Diagnostic workup for ARDS patients: Intensive Care Med, 2016; 42; 674-85

3.. Henrickson KJ, Parainfluenza viruses: Clin Microbiol Rev, 2003; 16; 242-64

4.. Branche AR, Falsey AR, Parainfluenza virus infection: Semin Respir Crit Care Med, 2016; 37; 538-54

5.. Chalkias S, Mackenzie MR, Gay C, DAS181 treatment of hematopoietic stem cell transplant patients with parainfluenza virus lung disease requiring mechanical ventilation: Transpl Infect Dis, 2014; 16; 141-44

6.. Shima T, Yoshimoto G, Nonami A, Successful treatment of parainfluenza virus 3 pneumonia with oral ribavirin and methylprednisolone in a bone marrow transplant recipient: Int J Hematol, 2008; 88; 336-40

7.. Kurai D, Sasaki Y, Saraya T, Pathogen profiles and molecular epidemiology of respiratory viruses in Japanese inpatients with community-acquired pneumonia: Respir Investig, 2016; 54; 255-63

8.. Alimi Y, Lim WS, Lansbury L, Systematic review of respiratory viral pathogens identified in adults with community-acquired pneumonia in Europe: J Clin Virol, 2017; 95; 26-35

9.. Radovanovic D, Sotgiu G, Jankovic M, An international perspective on hospitalized patients with viral community-acquired pneumonia: Eur J Intern Med, 2019; 60; 54-70

10.. Falsey AR, Walsh EE, Viral pneumonia in older adults: Clin Infect Dis, 2006; 42; 518-24

11.. Russell E, Ison MG, Parainfluenza virus in the hospitalized adult: Clin Infect Dis, 2017; 65; 1570-76

12.. Drozd DR, Limaye AP, Moss RB, DAS181 treatment of severe parainfluenza type 3 pneumonia in a lung transplant recipient: Transpl Infect Dis, 2013; 15; E28-32

13.. Koo HJ, Lim S, Choe J, Choi SH, Radiographic and CT features of viral pneumonia: RadioGraphics, 2018; 38; 719-39

14.. , Human parainfluenza viruses (HPIVs), for healthcare professionals, laboratory diagnosis, 2009 Available at: [accessed July 24 2021]https://www.cdc.gov/parainfluenza/hcp/lab.html

SARS-CoV-2/COVID-19

19 May 2022 : Case report  Serbia

Bilateral Emphysematous Pyelonephritis Associated with COVID Pneumonia: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.936370  

17 May 2022 : Case report  USA

High-Frequency Oscillatory Ventilation for Refractory Hypoxemia in Severe COVID-19 Pneumonia: A Small Case ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936651  

13 May 2022 : Case report  Japan

A case of exacerbation of haloperidol-induced rhabdomyolysis following the onset of COVID-19

Am J Case Rep In Press; DOI: 10.12659/AJCR.936589  

13 May 2022 : Case report  USA

Acute Disseminated Encephalomyelitis After SARS-CoV-2 Vaccination

Am J Case Rep In Press; DOI: 10.12659/AJCR.936574  

In Press

26 May 2022 : Case report  USA

Cardiac Tamponade as Initial Presentation of Systemic Lupus Erythematous in Third-Trimester Pregnancy

Am J Case Rep In Press; DOI: 10.12659/AJCR.936273  

25 May 2022 : Case report  Mexico

Acute Mitral Regurgitation Due to Chordae Tendineae Rupture: A Rare Presentation of Cardiac Amyloidosis

Am J Case Rep In Press; DOI: 10.12659/AJCR.936545  

25 May 2022 : Case report  USA

Pleural Effusion as the Initial Presentation of Gastric Adenocarcinoma: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.935434  

24 May 2022 : Case report  USA

Adalimumab Mitigates Lumbar Radiculopathy in a Case of Ankylosing Spondylitis

Am J Case Rep In Press; DOI: 10.12659/AJCR.936600  

Most Viewed Current Articles

23 Feb 2022 : Case report  USA

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

17 Feb 2022 : Case report  Oman

Myocarditis, Pulmonary Hemorrhage, and Extensive Myositis with Rhabdomyolysis 12 Days After First Dose of P...

DOI :10.12659/AJCR.934399

Am J Case Rep 2022; 23:e934399

06 Dec 2021 : Case report  Brazil

Lipedema Can Be Treated Non-Surgically: A Report of 5 Cases

DOI :10.12659/AJCR.934406

Am J Case Rep 2021; 22:e934406

19 Feb 2022 : Case report  USA

A Rare Case of Coronavirus Disease 2019 Vaccine-Associated Cerebral Venous Sinus Thrombosis Treated with Me...

DOI :10.12659/AJCR.935355

Am J Case Rep 2022; 23:e935355

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923