Patient: Male, 21Final Diagnosis: Hemophagocytic LymphohistiocytosisSymptoms: Acute respiratory insufficiency • anemia • thrombocytopeniaMedication: —Clinical Procedure: Extracorporeal membrane oxygenationSpecialty: HematologyObjective:Rare diseaseBackground:Hemophagocytic lymphohistiocytosis (HLH) is a rare hematological disease characterized by an excessive inflammatory response to various triggers, resulting in rapid multi-organ failure. Its incidence may be underestimated due to its rarity, its variable clinical presentation, and its high mortality rate prior to diagnosis. Oftentimes, HLH is mistaken for refractory sepsis and improperly treated as such. Left untreated, the disease is universally fatal. With treatment, case series of adults with HLH report a 30-day mortality of up to 44% and an overall mortality of up to 75%.Case Report:We describe the use of extracorporeal membrane oxygenation (ECMO) in a previously healthy young man with HLH and acute respiratory distress syndrome (ARDS), a common sequela of HLH. ECMO was employed to provide temporary hemodynamic support, allowing for recovery of pulmonary function compromised during the initial cytokine storm. Additionally, and perhaps more importantly, implementation of ECMO provided the time necessary for the eventual diagnosis and treatment of HLH.Conclusions:Although limited case reports and case series suggest that the use of ECMO in pediatric patients with HLH is associated with high mortality, our experience suggests that ECMO should not be rejected as a supportive modality in adults with HLH who have potentially recoverable cardiopulmonary function. We believe that ECMO may be appropriately instituted in select patients with HLH, or in rapidly deteriorating patients with an unknown illness refractory to conventional therapy, to allow for end-organ recovery, to reach a diagnosis, and to administer appropriate therapy.

The hemodynamic effects of small-volume boluses of hyperosmotic solutions are often deemed negligible in the clinical setting. However, animal studies have reported decreases in systemic arterial blood pressure and bradycardia with the administration of hyperosmotic solutions. This is a report of a 60-year-old woman, intubated and sedated, who developed acute decreases in systemic arterial blood pressure with the administration of ≤50 mL of 50% dextrose. Animal studies suggest that hyperosmolar-induced hypotension may be avoided by administering the hyperosmotic solution slowly. This allows for admixture and therefore a decreased osmotic load at the proposed osmoreceptor involved in the neural reflex.