ATG-Induced Capillary Leak Syndrome: A Successful Turnaround

Dear Editor,

A 51-year-old male admitted for renal transplantation was started on antithymocyte globulin (ATG) as part of the induction regimen. He had undergone hemodialysis with 2.5 L of ultrafiltration. Post-dialysis chest X-ray was normal. Two hours into ATG infusion, he developed a severe headache, a sensation of sinking, and acute respiratory distress with copious frothy sputum. On examination, the patient was restless with a respiratory rate of 30/min, hypotensive (BP 90/60 mmHg), and tachycardic. Arterial blood gas (ABG) analysis indicated Type II respiratory failure, and non-invasive ventilation (NIV) support was initiated. Laboratory investigations showed raised procalcitonin (28 ng/mL), hypoalbuminemia (3.15 g/dL), and a recent rise in hematocrit (41% from 28%). Chest radiography revealed bilateral fluffy opacities, and a CT scan of the chest demonstrated focal and diffuse ground glass opacities (GGOs) in the right middle lobe and bilateral lower lobes [Figure 1]. Sputum analysis was unremarkable with sterile blood culture and normal 2D-Echo.

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Figure 1: (a) Chest X-ray posteroanterior view shows bilateral fluffy opacities, and (b) high resolution computed tomography chest shows focal and diffuse ground glass opacities in the right middle lobe and bilateral lower lobes.

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In addition to NIV support, the patient received hemodiafiltration and was given pulse methylprednisolone for two days. Thereafter, transplantation was deferred.

Over the next 3–4 days, the patient improved with normalization of procalcitonin levels and resolution of radiographic abnormalities. Subsequently, renal transplantation was successfully performed with Graflon (ATG-Fresenius) as an induction agent.

Systemic capillary leak syndrome (SCLS) is a rare but serious complication of ATG therapy. It typically presents with respiratory distress, hypotension, hemoconcentration, hypoalbuminemia, and normal cardiac function.¹ A transient rise in procalcitonin following ATG administration, resolving within 3–4 days, has been reported and should not be misinterpreted as infection.²

This case highlights the early occurrence, timely diagnosis, and successful management of SCLS. It underscores that post-ATG elevation of procalcitonin does not necessarily indicate infection.