A Complex Case of Multifactorial Hypoxemia from Metastatic Testicular Cancer

A 27-year-old male with no known past medical history presented for evaluation of a 14.1 cm testicular mass (Figure A). He was found to have severe anemia (Hgb 2.8 g/dL), and biopsy demonstrated a non-seminomatous mixed germ cell tumor of testicular origin with imaging demonstrating widespread metastases to the brain, lungs, and liver. The patient received multiple blood transfusions and one dose of bleomycin, etoposide, and cisplatin followed by the development of acute respiratory failure. Computed tomography angiography (CTA) chest was negative for pulmonary thromboembolism but demonstrated diffuse ground-glass opacities (Figure B, arrows) and metastatic pulmonary masses containing dilated vessels suspicious for arteriovenous malformations (Figure C, arrows). It was theorized that this decompensation could be a result of volume overload after receiving 15 units packed red blood cells (pRBCs), transfusion-related acute lung injury (TRALI), infection, cytokine release, and/or chemotherapy toxicity. The patient was intubated and started on high dose steroids, antibiotics, sedatives, paralyzing agents, and epoprostenol. Workup for infection was negative, and bronchoscopy was without alveolar hemorrhage. The patient was unable to receive further rounds of chemotherapy given the high risk for oxidative toxicity and degree of acute illness. Due to lack of improvement, the patient required extracorporeal membrane oxygenation (ECMO) cannulation and continuous veno-venous hemodialysis (CVVHD). Unfortunately, due to continued deterioration, he was transitioned to comfort measures and expired. This case highlights the likely combined effects and complex interactions of chemotherapy toxicity, metastatic disease, and circulatory overload contributing to respiratory failure.