# Severe hyperbilirubinemia secondary to ECMO in a ARDS patient: a case report

## TL;DR

A patient on ECMO for severe respiratory failure developed severe hyperbilirubinemia due to immune-mediated hemolysis and was successfully treated with a combination of therapies.

## Contribution

This case report presents a rare instance of immune-mediated hemolysis during ECMO and demonstrates an effective combined treatment strategy.

## Key findings

- Severe hyperbilirubinemia with hemolysis occurred in a patient on ECMO for ARDS.
- Immune-mediated hemolysis was confirmed through immunohematological tests.
- A combined therapy approach successfully normalized bilirubin levels and led to recovery.

## Abstract

A 51-year-old male presented with a 9-day history of fever and cough, progressing to severe respiratory failure refractory to conventional management.

High-throughput sequencing confirmed influenza A virus. Chest CT revealed bilateral pneumonia and pulmonary edema. Due to a persistently low oxygenation index (PaO₂/FiO₂ 48.9 mmHg), veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated.

The patient was managed with a lung-protective ventilation strategy, prone positioning, and appropriate antimicrobial therapy. During ECMO support, severe mixed hyperbilirubinemia with a significant hemolytic component developed, characterized by a peak total bilirubin of 887 μmol/L. Management of hyperbilirubinemia included liver-protective agents, dual plasma molecular adsorption system (DPMAS), and therapeutic plasma exchange. Immunohematological tests confirmed immune-mediated hemolysis (positive direct and indirect antiglobulin tests).

Following ECMO decannulation, bilirubin levels normalized. The patient was successfully weaned from mechanical ventilation, transferred to a general ward, and eventually discharged, achieving full social reintegration.

This case highlights the diagnostic challenge of differentiating between mechanical and immune-mediated hemolysis in ECMO patients and demonstrates the successful application of a combined therapeutic approach for severe ECMO-associated hyperbilirubinemia.