Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Med. Feb 4, 2017; 6(1): 85-90
Published online Feb 4, 2017. doi: 10.5492/wjccm.v6.i1.85
Intravenous vitamin C as adjunctive therapy for enterovirus/rhinovirus induced acute respiratory distress syndrome
Alpha A Fowler III, Christin Kim, Lawrence Lepler, Rajiv Malhotra, Orlando Debesa, Ramesh Natarajan, Bernard J Fisher, Aamer Syed, Christine DeWilde, Anna Priday, Vigneshwar Kasirajan
Alpha A Fowler III, Rajiv Malhotra, Orlando Debesa, Ramesh Natarajan, Bernard J Fisher, Aamer Syed, Christine DeWilde, Anna Priday, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
Christin Kim, Department of Anesthesia Critical Care, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
Lawrence Lepler, Division of Critical Care Medicine, INOVA Fair Oaks Hospital, INOVA Health Care System, Fairfax, VA 22042, United States
Vigneshwar Kasirajan, Division of Cardiothoracic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, United States
Author contributions: Fowler III AA is principal investigator, corresponding author, and contributed to study concept, basic and translational research; Kim C and Lepler L contributed to patient’s clinical care, patient follow-up and manuscript review; Malhotra R contributed to patient’s clinical care; Debesa O contributed to patient’s clinical care and manuscript review; Natarajan R and Fisher BJ contributed to manuscript creation, basic research leading to clinical use; Syed A and Kasirajan V contributed to clinical care and manuscript creation; DeWilde C contributed to clinical care and laboratory coordination; Priday A contributed to FDA regulatory coordinator for IND used for study.
Institutional review board statement: The use of intravenous vitamin C in humans has been approved by the Virginia Commonwealth University Institutional Review Board (HM20000917).
Informed consent statement: Permission for the patient to receive intravenous vitamin C as described in this case report was granted by the patient’s legal next of kin. All patient health information was de-identified and held in strictest confidentiality.
Conflict-of-interest statement: All authors have no conflicts of interests to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Alpha A Fowler III, MD, William Taliaferro Thompson Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, PO Box 980050, Richmond, VA 23298, United States. alpha.fowler@vcuhealth.org
Telephone: +1-804-8289071 Fax: +1-804-8282578
Received: July 12, 2016
Peer-review started: July 13, 2016
First decision: September 2, 2016
Revised: October 26, 2016
Accepted: November 16, 2016
Article in press: November 17, 2016
Published online: February 4, 2017
Abstract

We report a case of virus-induced acute respiratory distress syndrome (ARDS) treated with parenteral vitamin C in a patient testing positive for enterovirus/rhinovirus on viral screening. This report outlines the first use of high dose intravenous vitamin C as an interventional therapy for ARDS, resulting from enterovirus/rhinovirus respiratory infection. From very significant preclinical research performed at Virginia Commonwealth University with vitamin C and with the very positive results of a previously performed phase I safety trial infusing high dose vitamin C intravenously into patients with severe sepsis, we reasoned that infusing identical dosing to a patient with ARDS from viral infection would be therapeutic. We report here the case of a 20-year-old, previously healthy, female who contracted respiratory enterovirus/rhinovirus infection that led to acute lung injury and rapidly to ARDS. She contracted the infection in central Italy while on an 8-d spring break from college. During a return flight to the United States, she developed increasing dyspnea and hypoxemia that rapidly developed into acute lung injury that led to ARDS. When support with mechanical ventilation failed, extracorporeal membrane oxygenation (ECMO) was initiated. Twelve hours following ECMO initiation, high dose intravenous vitamin C was begun. The patient’s recovery was rapid. ECMO and mechanical ventilation were discontinued by day-7 and the patient recovered with no long-term ARDS sequelae. Infusing high dose intravenous vitamin C into this patient with virus-induced ARDS was associated with rapid resolution of lung injury with no evidence of post-ARDS fibroproliferative sequelae. Intravenous vitamin C as a treatment for ARDS may open a new era of therapy for ARDS from many causes.

Keywords: Intravenous vitamin C, Acute respiratory distress syndrome, Enterovirus/rhinovirus, Acute lung injury, Extracorporeal membrane oxygenation

Core tip: Enterovirus/rhinovirus has been reported to cause devastating acute lung injury. We report here the first use of high dose intravenous vitamin C to attenuate the acute respiratory distress syndrome that was caused by this viral infection. We have previously reported that vitamin C used in this interventional fashion is a potent anti-inflammatory agent.