Insufficient serum levels of antituberculosis agents during venovenous extracorporeal membrane oxygenation therapy for acute respiratory distress syndrome in a patient with miliary tuberculosis.

Prolonged cardiopulmonary support via extracorporeal membrane oxygenation (ECMO) is essential for patients with life-threatening respiratory or cardiac failure. Extracorporeal membrane oxygenation is known to be associated with conditions that potentially alter the distribution and elimination properties of drugs. However, little has been documented concerning pharmacokinetic changes of antibacterial agents in critically ill patients under oxygenation conditions. We describe a case of miliary tuberculosis with acute respiratory distress syndrome supported by venovenous ECMO. The patient had persistently positive acid-fast bacilli smears for respiratory specimens. Accordingly, standard doses of antituberculosis agents, including isoniazid, rifampicin, ethambutol, and pyrazinamide, were administered with appropriate therapeutic drug monitoring. Drug levels were found to be subtherapeutic. Therapeutic target levels were achieved after altering the route of administration and making dosage adjustments. Although this is a single case report, our observations indicate the need for therapeutic drug monitoring to achieve appropriate target concentrations for antituberculosis agents in patients with miliary tuberculosis under ECMO.