Veno-venous extracorporeal membrane oxygenation support for severe leptospirosis complicated by pulmonary hemorrhage and refractory acute respiratory distress syndrome: A case report and literature review

Rationale: Leptospiral pulmonary hemorrhage syndrome is a rare but life-threatening manifestation of leptospirosis and is frequently complicated by acute respiratory distress syndrome, with persistently high mortality. Using veno-venous extracorporeal membrane oxygenation (VV-ECMO) in this setting remains challenging because systemic anticoagulation may exacerbate pulmonary bleeding. Patient concerns: A 58-year-old male farmer presented with high fever, myalgia, and rapidly progressive dyspnea following possible environmental exposure. He developed severe hypoxemia accompanied by diffuse pulmonary hemorrhage and multi-organ dysfunction. Diagnoses: According to clinical presentations, radiologic findings, and next-generation sequencing of peripheral blood, the diagnosis of severe leptospirosis complicated by pulmonary hemorrhage and refractory acute respiratory distress syndrome was established. Interventions: Despite lung-protective mechanical ventilation and adjunctive prone positioning, hypoxemia persisted. VV-ECMO was initiated as rescue therapy using an individualized anticoagulation strategy. Continuous renal replacement therapy with regional citrate anticoagulation was employed to minimize systemic anticoagulant exposure. Pathogen-directed antimicrobial therapy was promptly instituted following microbiological confirmation. Outcomes: The patient exhibited progressive improvement in oxygenation and organ function. VV-ECMO was successfully weaned after 6 days, followed by extubation and transfer out of the intensive care unit with stable respiratory status. Lessons: VV-ECMO may be considered a viable therapy for life-threatening hypoxemia in leptospiral pulmonary hemorrhage when the underlying disease is potentially reversible. Individualized anticoagulation strategies and continued application of lung-protective measures, including prone positioning when feasible, are critical to optimizing outcomes.