Although she was diagnosed 8 years ago, and has been treated with a course of Cytoxan in the past, and prednisone for three years, this is her first serious flare up that required hospitalization and significant complications of the autoimmune disease, including respiratory failure, acute renal failure and pericarditis. A quick discussion with her rheumatology team confirmed that there are multiple options for both acute treatment of her disease and for a maintenance program.

She is taken to the operating room and placed on VV ECMO with a 31 French double lumen cannula, positioned under fluoroscopic guidance. She returned to the ICU and was immediately started on her first of four daily courses of plasmapheresis per the rheumatology orders, along with high dose IV steroids. A routine flexible bronchoscopy was clear. Her urine output was insufficient and she eventually became anuric and CVVHD was started to remove fluid. Her lungs fields cleared on CXR and her compliance improved over the next several days, and her small pericardial effusion resolved. The improvement was fast enough that we elected to defer tracheostomy and plan for early extubation. After 5 days of ECMO she was successfully weaned and decannulated, was extubated the following day, and transferred out of ICU 2 days later. She had placement of a dialysis catheter for continued dialysis, and was started on PO Cytoxan and discharged to home 11 days post ECMO.