Characteristics and Outcome of Patients with Influenza A (H1N1 ...

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Egyptian Journal of Medical Microbiology, January 2010 Vol. 19, No. 1Fig. 1: Percentage of signs and symptoms of Infleunza H1N1 in confirmed cases.Table 2: Most common comorbidities ofpatients with pandemic Infleunza H1N1ComorbiditiesNo. ofcases%Number of comorbidities :- Non- 1 comorbidity- >1 comorbidity66201168%20.611.4Type of comorbidity:Smoking 18 18.6%Lung diseases:- BA 112- COPD 27- ARDS 32- Pickwickian syndrome 4 112.4%7.22.11.03Obesity 1 1.03Hypertension 3 3.1Pregnancy 4 4.1Hear diseases :- SVT 5- IHD 6- Rheumatic heart1111.031.031.03Diabetes Mellitus 4 4.1Renal transplant 1 1.03Herpes simplex 1 1.03Allergic Rhinitis 1 1.03Hypothyrodism 2 2.1Cancer 2 2.1Congenital : Down syndrome 1 1.031 Bronchial asthma; 2 Chronic obstructive lungdisease; 3 Acute respiratory distress syndrome4 hypoventilation syndrome;5 supraventriculartachycardia; 6 Ischemic heart diseaseOnly confirmed patients of H1N1 infectionby RT –PCR were included in this study. PCRwas negative in two patients at ICU admission;they were later confirmed to have the infectionthrough further determination of trachealsecretions.All patients in the study were recoveredtotally except 2 who required mechanicalventilation due to viral primary pneumoniawith chest radiograph of bilateral patchyalveolar opacities (predominantly basal) thatprogressed rapidly to affect all lung fields(Acute Respiratory Distress Syndrome) (ARDS)finding.The first patient was female patient, 60years old with COPD, whom complaint startedabout 10 days before admission, this patientdied within 12 hrs. Another 30 years pregnantfemale with BA, who died after 1 month due tomultiorgan failure. Chest computed tomographyscan was performed on this patient and showedairspace consolidation and ground glass opacityin the multilobar and bilateral distribution. Shealso had elevated direct and indirect bilirubin,high creatinine level and high liver enzymes(ALT and AST). For this patient, abdominalultra-sonograghy revealed only congested liverwith normal diameter of common bile duct.An amazing two old women patient, 75years old, with COPD, and ischemic heartdisease (IHD) and who had gastrectomy due toprevious cancer stomach. Another woman 72years with concurrent laryngeal carcinoma.Both recovered without complications.86
Egyptian Journal of Medical Microbiology, January 2010 Vol. 19, No. 1No patient was complicated with secondarybacterial pneumonia or associated withbacteriamia .7 cases of influenza H1N1 were reported innurses due to contact with patientsDISCUSSIONSince 2000, the WHO has promptedcountries to prepare for a potential influenzapandemic. Activities included the introductionof yearly influenza vaccination and a strategicreserve of oseltamivir, antibiotics, andprotective items for health care personnel wasestablished in 2006 9 . Since the emergence of thenovel H1N1 influenza 2009 in mid April, thenumber of confirmed cases has increased tomillions across the world with at least 17000deaths till writing this study 10 .Table 3: Characteristics of 97 patientsconfirmed of H1N1 infleunza virus.VariablesValueAge years (mean ± SD) 34.5± 16.99Male (No. , %) 52 (53.6%)Female (No. , %) 45 (46.4%)Leucopenia (No. , % ) ( 88 , 91% )Less than 3000/mm 3Median number of days (1.5 days ± 0.6)from illness onset toinitiation of antiviral ttt(mean ± SD)No. of patients receiving 97 (100%)antiviral ttt before testingresults available.Duration of oseltamivir tttClinical outcome: (No.,%)CuredDiedTransferredMechanical ventilation(No. , % )- No- YesRange ( 5-10 days)(6 ± 1.8)95 (97.9 %)1 (1.03% )1 (1.03% )95 (97 .9%)2 (2.1%)Most of our patients were young to middleagedand had previously been healthy. Themajority of infections reported have been mild,influenza-like illnesses. This has been reportedin other countries 11,12 .Fever, fatigue and respiratory symptomswere harbingers of disease in almost all cases inthis study and in others 12,13, 14 .The most common comorbidities amongpatients in this study were lung diseases and ahistory of smoking. This agreed with otherstudies 9,12,13 . Also Kumar et al. 12 reported thatamong critically ill patients, obesity has beenshown to be a risk factor for increasedmorbidity, but not consistently with mortality.The association of obesity with severe 2009influenza A (H1N1) infection has been reportedby others 13,14,15 , and may be a novel finding ofthis pandemic.This study has point of strength. It includesboth adults and children from geographicallyand racially diverse settings across MadinahMonawarha region, which improves thegeneralizability of our results to other regions.The tendency of females to develop severe2009 influenza A (H1N1) infection in this seriesis striking. A general female susceptibility hasnot been observed in other influenza case seriesof variable severity including the initial reportsof 2009 influenza A (H1N1) infections 3 . Inmost infectious diseases and related conditionssuch as sepsis and septic shock, males representa larger proportion of cases and have a highermortality 16 . The explanation for increased riskof severe disease and death among females isunclear but the role of pregnancy as a risk factorhas been noted in previous influenzapandemics 17 . In spite of that the 4 pregnantcases in this study recovered completely withoutcomplications, maybe due to the earlyintroduction of antiviral as recommended byWHO 18 .Padilla et al. 9 reported that false negativetest in patients would be more likely if the testwere delayed (as the 2 cases in this study), or ifpatients had limited viral shedding. Theynoticed that patients who tested negative forH1N1 had a milder clinical course than thosewho tested positive but were as much a part ofthe burden of the epidemic as those who werenot tested.Unusual features of severe disease in thecurrent pandemic compared with most previouswell characterized pandemics, including the(probable) H2N2 1890 Russian influenzapandemic, the H2N2 1957 Asian influenzapandemic, and the H3N2 1968 Hong Kongpandemic. In these previous influenzapandemics, an increased predilection forinfection among children and young adults hasbeen documented 19 although mortality curveswere U shaped with increased deaths in the veryyoung and the aged. Data suggested 12,13 thatsevere disease and mortality in the currentoutbreak is concentrated in relatively healthyadolescents and adults between the ages of 10and 60 years, a pattern reminiscent of the W-87
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