Recurrent Hydrochlorothiazide-Induced Acute Respiratory Distress Syndrome Treated With Extracorporeal Membrane Oxygenation

Abstract

Background: Hydrochlorothiazide (HCTZ) is a commonly prescribed sulfonamide thiazide-type diuretic medication that has been associated with rare cases of noncardiogenic pulmonary edema.

Case report: A man in his 50s with a medical history notable for hypertension was transferred to our institution for evaluation of refractory hypoxemia. After taking an initial dose of HCTZ earlier in the day, he developed progressive respiratory failure and was intubated at a referring hospital. Progressive hypoxemia and acute respiratory distress syndrome (ARDS) developed and he was transferred to our institution for extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (vv-ECMO) was initiated in the Emergency Department and he was admitted to the intensive care unit. After several days of ECMO, his ARDS resolved and he was decannulated and extubated. Further history indicated that he had had two previous episodes of ARDS in the setting of HCTZ use without recognition of the inciting trigger, likely explaining his presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: One of the most commonly prescribed antihypertensives, HCTZ is associated with rare cases of pulmonary edema, which typically develop within minutes to hours of the initial dose of the medication. Although most cases resolve with supportive care, severe cases may require intubation and even vv-ECMO. The mechanism of the reaction is unknown, and affected individuals are typically able to tolerate other sulfonamide medications without issue.

Keywords: acute respiratory distress syndrome; adverse drug reaction; extracorporeal membrane oxygenation; hydrochlorothiazide; pharmacology; pulmonary edema.