Successful Treatment of COVID-19 Patient on ECMO Using Mesenchymal Stromal Cells (MSC)-Derived Exosomes: A Case Report

INTRODUCTION: The use of mesenchymal stromal cells (MSC) was recently proposed as a promising intervention for COVID-19 related respiratory failure (RF). Prior studies have suggested that its larger size might lead to entrapment in extracorporeal membrane oxygenation (ECMO), affect circuit function, and attenuate its efficacy. We present a successful case of a severe COVID-19 patient treated with MSC-derived exosomes while receiving veno-venous (VV) ECMO support. CASE REPORT: 41-year-old unvaccinated obese White male with no past medical history presenting with shortness of breath and a +COVID-19 nasopharyngeal test was admitted receiving high-flow nasal cannula (HFNC), remdesivir, and dexamethasone (Day 1), followed by intubation (day 5), and a peripheral VV ECMO insertion (day 10) due to worsening RF. We used bivalirudin for post-ECMO anticoagulation. Subsequently, he received the first cycle of MSC-derived exosomes on alternative days (day 1, 3, & 5) between days 13-17, followed by the second cycle between days 34-38. After administration of exosomes, the plasma concentration of inflammatory markers reduced, including a decrease of 77% for ferritin, 74% for CRP, and 62% for procalcitonin in approximately one week, along with consistent improvement of PaO(2)/FiO(2) ratio. ECMO membrane oxygenator was exchanged on day 23 at the time of tracheostomy. After successful weaning, ECMO decannulation was performed on day 47, and the patient was discharged home on day 61. SUMMARY: ECMO has emerged as a supportive strategy for patients with severe COVID-19 related RF. The patient's inflammatory response has been implicated in the pathophysiology of lung failure. Multiple pharmacological methods are employed to control the severity of this inflammatory response, thus preventing progression to the fibrotic stage of the disease. In our experience, MSC-derived exosomes neither resulted in any side effects nor impaired the function of ECMO and might have enhanced the recovery of the patient.