A fatal case of acute progression of generalized edema and simultaneous flash pulmonary edema in a patient with idiopathic systemic capillary leak syndrome: a case report

We describe a 65-year-old woman who was hospitalized because of severe hypovolemic shock with hemoconcentration and hypoalbuminemia. Our case was similar to other reports describing patients with SCLS and was diagnosed as severe SCLS according to the report by Gousseff et al. [5]. SCLS is diagnosed clinically after exclusion of other diseases that cause systemic capillary leakage, including severe sepsis, toxic shock syndrome and anaphylaxis. In our patient, blood cultures were negative and there were no findings of infection by autopsy, which indicated she had not had sepsis. Her cutaneous and respiratory findings, and laboratory examinations, showed that she had not had toxic shock syndrome and anaphylaxis.

SCLS attack consists of three phases, a prodromal phase, peripheral leak phase and recruitment phase [3]. About 30% of SCLS patients show an antecedent upper respiratory tract infection or a flu-like illness with fever in the prodromal phase, like our patient. One to four days after the prodromal phase, the capillary leakage develops and results in generalized edema, mainly in the trunk and extremities, while the visceral organs like lungs, brain, heart and kidneys usually seem not to be involved [3,5]. Some patients have hypovolemic shock and ischemic end-organ damage, which include acute kidney injury, ischemic brain injury and ischemic hepatic dysfunction. The peripheral leak phase continues for several days and the recruitment phase begins quickly, in which massive fluid and macromolecules are recruited back from the third space into the circulation. The patient is at high risk for intravascular volume overload and pulmonary edema during this recruitment phase. The reported cases of the acute phase of SCLS in the literature (from 1990 to 2011, [2,7,8,10-16]) are summarized in Table 1. Five out of 13 patients had pulmonary edema, which occurred in the recruitment phase in four of them and the other one patient had it in the peripheral leak phase because of the iatrogenic effect of the large amount of transfusion (case 10). Kapoor et al. evaluated 25 patients with SCLS to determine clinical features, natural history and outcome [4] Pulmonary edema developed in 10 out of 25 patients (40%) during the recovery phase in the face of ongoing vigorous fluid resuscitation. Therefore, in the peripheral leak phase, adequate organ perfusion has to be obtained by sequential rapid and large infusion of intravascular fluids if hypoperfusion exists. In the recruitment phase, control of the fluid overload must be performed with the use of diuretics and sometimes by mechanical ventilation [3].

In SCLS, the endothelial barrier dysfunction leads to leakage of the intravascular fluid and macromolecules like albumin into the interstitial space. Although crystalloids are used commonly as intravascular fluids, colloid (albumin) also should be used for the intravascular fluid resuscitation in SCLS, because colloid increases intravascular oncotic pressure and keeps the fluid in the intravascular space for a longer period than crystalloid alone [3]. However, proteins like albumin, with a molecular weight less than 200 kilodaltons, leak from the vessels in SCLS and the effectiveness of colloid may not be enough. Recently, it was reported that the infusion of 10% pentastarch, a larger molecule than albumin, had the effect to stabilize the hemodynamics in two SCLS patients with refractory hypotension during the peripheral leak phase, who did not respond to aggressive crystalloid replacement and inotropic agents [13]. The pharmacologic therapies to improve the capillary leakage were tried in the acute phase of SCLS. Terbutaline, by inducing adenyl cyclase, and theophylline, by inhibiting phosphodiesterase, increase the cyclic adenosine monophosphate (cAMP) levels of the endothelium. The increase in cAMP is known to decrease endothelial cell permeability [17], and so both are supposed to interfere with capillary permeability. Beta-2 stimulators like terbutaline can also inhibit macromolecular leakage in response to histamine and bradikynin [18]. Theophylline also is known to antagonize cytokine-mediated endothelial damage and capillary permeability [19]. Through these pharmacologic activities, both terbutaline and theophylline are used as a first-line prophylactic therapy against chronic SCLS [20]. In three patients with acute phase SCLS, Dowden et al. showed that the combination of terbutaline and theophylline had beneficial effects by decreasing capillary permeability if the serum theophylline level was high enough (20 to 25mcg/mL), and that if it did not work, the additional administration of tumor necrosis factor alpha (TNF-alpha) antagonist (infliximab) seemed to improve the patient refractory to terbutaline and theophylline [21]. Lambert et al. reported high-dose intravenous immunoglobulins were effective against the acute phase of SCLS [22]. VEGF was reported in 1983 to induce rapid leakage from blood vessels [23]. Recently, VEGF was reported to increase in the episodic SCLS active phase but not in the remission phase [24,25]. Yabe et al. reported that anti-VEGF antibody (bevacizumab) improved the life-threatening acute phase of SCLC [26]. However, we need to be aware of SCLS and to diagnose it before using them, because these acute pharmacologic challenges are not established and a TNF-alpha antagonist is dangerous if patients have sepsis.

Our patient was hospitalized in the peripheral leak phase of SCLS with prolonged hypoperfusion, because she had distributive shock with metabolic acidosis. Although we did not have a definitive diagnosis, we started infusing extracellular fluid (crystalloid) without colloid, and her hemodynamics improved transiently. Usually, the lungs may not be involved in the peripheral leak phase [3]. But during the extracellular fluid infusion, the generalized edema progressed and the severe flash pulmonary edema also progressed rapidly, and she died (Figure 3). There might be several possible explanations. The rapid decrease in oncotic pressure due to severely progressing hypoalbuminemia and the increase in the pulmonary artery resistance due to metabolic acidosis [27,28] and the aggressive extravascular fluid resuscitation without colloid, all of them might induce flash pulmonary edema. Although we thought the serum albumin level of 3.1g/dL on admission was mild, its level had to have been actually very low in consideration of her severe hemoconcentration. The degree of hypovolemia and systemic tissue hypoperfusion on admission were also severe in consideration of her metabolic acidosis and hemoconcentration, and so the pulmonary capillary hydrostatic pressure was low enough not to induce pulmonary edema in spite of her hypoalbuminemia on admission. Therefore, we should have understood the pathogenesis of the SCLS and have transfused the appropriate dose of colloids with crystalloids while monitoring the central venous pressure on admission and performed mechanical ventilation with positive end-expiratory pressure (PEEP) at the latest at the occurrence of the first hemodynamic deterioration. The myocardial involvement associated with the SCLS might be another possibility [11,29,30]. Claessens et al. showed the reversible biventricular wall thickening, while systolic function remained normal by echocardiography. The ECG revealed cardiac axial rotation of −30° with nonspecific repolarization abnormalities in the attacks of SCLS, as in our patient [11]. Juthier et al. observed both myocardial thickening and severe systolic dysfunction by echocardiography, and diffuse myocardial interstitial edema without inflammatory infiltrates and myocyte necrosis by endomyocardial biopsies in the shock stage in one patient with SCLS [29]. In our patient, the autopsy findings did not show myocardial interstitial edema.

The pathogenesis of SCLS is unknown. Some hypotheses have been proposed, but hypotheses have incomplete evidence [3]. About 80% of patients with SCLS have a monoclonal immunoglobulin in their serum and these paraproteins might be related to the endothelial damage and vascular leakage [5,8,31]. But our patient did not have a monoclonal immunoglobulin. Some reports proposed the role of the cytokines, because interleukin 2 (IL-2)-receptor positive cells and cluster of differentiation 8 (CD8)-positive lymphocytes were found surrounding damaged endothelial cells during attacks in one patient [32]. However, in our patient, we could not find the lymphocytes around the capillaries of the autopsy tissues. VEGF is considered to be related to the pathogenesis of SCLS [23-25]. In our patient, VEGF was within normal limit. Therefore, the etiology of our patient remains unknown.