Abstract Introduction Unicentric Castleman disease (UCD) may rarely trigger paraneoplastic pemphigus (PNP) with secondary bronchiolitis obliterans (BO) through autoantibodies directed against epithelial adhesion proteins such as envoplakin. BO in this setting frequently progresses despite resection of the lymphoproliferative lesion and immunomodulatory therapy, and may result in end-stage hypercapnic respiratory failure where lung transplantation becomes the only definitive therapy. Published experience describes difficulty liberating from mechanical ventilation and slow post-transplant recovery. Reports of awake VV-ECMO bridging for paraneoplastic BO remain extremely limited. Case A 39-year-old woman with unicentric hyaline-vascular Castleman disease, paraneoplastic pemphigus, and severe small-airway-dominant bronchiolitis obliterans developed progressive hypercapnic respiratory failure despite rituximab, IVIG, and glucocorticoids. Airflow obstruction worsened even after lymph node resection. She required intubation and was transitioned to VV-ECMO for gas exchange stabilization. Within 24 hours, she was extubated to awake VV-ECMO, enabling active rehabilitation. During transplant evaluation, anti-envoplakin titers showed a down-trending pattern, supporting controlled autoimmune activity. She underwent bilateral lung transplantation with negative crossmatch. Her postoperative course was uncomplicated; ECMO and ventilatory support were weaned early. She was discharged home on postoperative day 21, ambulatory on room air. Discussion Castleman disease complicated by paraneoplastic pemphigus-associated bronchiolitis obliterans is a rare immune-mediated small-airway disorder that often progresses despite tumor resection and immunosuppression. Lung transplantation is feasible but prior reports frequently describe prolonged mechanical ventilation, non-awake ECMO support, and extended postoperative recovery. More recent case reports, such as Kteiche et al. (2025), highlight the importance of early recognition of autoimmune airway injury but still note challenging peri-transplant courses. In this case, awake VV-ECMO allowed stabilization while maintaining spontaneous breathing and participation in rehabilitation, preserving pre-transplant conditioning. Down-trending anti-envoplakin titers indicated controlled autoimmune activity and informed transplant timing. The patient’s rapid postoperative recovery suggests that awake ECMO bridging with functional preservation may improve transplant readiness and early outcomes in Castleman-associated BO. Conclusion Awake VV-ECMO with early extubation may be a useful bridge strategy in Castleman-associated bronchiolitis obliterans. Monitoring autoantibody trends can help determine transplant timing, while preserving functional conditioning before surgery may support faster, more successful recovery in this high-risk population. This abstract is funded by: None
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