Influenza Virus Net is the web resource for anyone interested in influenza and flu pandemics. The objectives of Influenza Virus Net are to be the public and professional information resource for influenza and to serve as a network in the exchange of information and news related to influenza.
Influenza, commonly referred to as the flu, is an infectious disease caused by RNA viruses of the family Orthomyxoviridae (the influenza viruses), that affects humans, birds and other mammals. The virus spreads easily from person to person. Influenza circulates worldwide and can affect anybody in any age group. Influenza causes annual epidemics that peak during winter in temperate regions. Influenza is a serious public health problem that causes severe illnesses and deaths for higher risk populations. The most common symptoms of the disease are chills, fever, sore throat, muscle pains, severe headache, coughing, weakness/fatigue and general discomfort. Sore throat, fever and coughs are the most frequent symptoms. In more serious cases, influenza causes pneumonia, which can be fatal, particularly for the young and the elderly. An influenza epidemic can take an economic toll through lost workforce productivity, and strain health services. Vaccination is the most effective way to prevent infection.
- Kids and flu shots - MyFox Atlanta
Thu, 23 Oct 2014 02:56:
- Peninsula prepared for Ebola, but flu's a bigger threat, health officer says - Peninsula Daily
Thu, 23 Oct 2014 02:44:
- Doctors: Don't forget about the flu - WKYT
Thu, 23 Oct 2014 02:44:
- Butte hospital taking Ebola precautions; flu bigger threat - Montana Standard
Thu, 23 Oct 2014 02:33:
- From the Farm | Annual flu clinic successful once again - Myhorrynews
Thu, 23 Oct 2014 02:29:
- Flu arrives early at Washington State University - KING5.com
Thu, 23 Oct 2014 02:25:
- Flu shot clinics today at two sites - The Trinity Journal
Thu, 23 Oct 2014 02:13:
- Drive thru flu shot clinic helps 800 people - WAAY
Thu, 23 Oct 2014 02:09:
- Health department offers walk-in flu clinic - The Republic
Thu, 23 Oct 2014 01:59:
- Influenza Titer on Chip(R) Now Available as Robust Flu Vaccine Potency Assay - Korea IT Times (press release)
Thu, 23 Oct 2014 01:48:
- PRO/EDR> Influenza (31): WHO global update
Tue, 21 Oct 2014 21:29:31
Influenza -- Worldwide
Globally, influenza activity remained low, with the exception of some tropical countries in the Americas and some Pacific Islands.
- In Europe and North America, overall influenza activity remained at inter-seasonal levels.
- In tropical countries of the Americas, influenza B co-circulated with respiratory syncytial virus (RSV).
- In Africa and western Asia, influenza activity was low.
- In eastern Asia, influenza activity in most countries remained low or decreased
- Preemptive Use of Oseltamivir in Lung Transplant Recipients: A One-Year Observational Study of Clinical Characteristics, Outcomes, Comedication and Safety.
Jungo C, Russmann S, Schuurmans M Preemptive Use of Oseltamivir in Lung Transplant Recipients: A One-Year Observational Study of Clinical Characteristics, Outcomes, Comedication and Safety. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):980A.Lung Transplantation PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Influenza virus infections in lung transplant recipients (LTRs) have an increased risk of unfavorable outcomes. Early initiation of treatment is associated with improved outcomes. In clinical practice oseltamivir is therefore commonly started even prior to diagnostic microbiological confirmation. There is limited data on the patient characteristics, safety of oseltamivir and outcomes of this practice. The aim of this study is to asses patient and treatment characteristics as well as safety of this preemptive treatment strategy using oseltamivir.Descriptive analysis of LTRs who received oseltamivir for ≥2 days for suspected influenza infection between 07-2011 and 06-2012. Analyses were based on data from electronic medical records and our standardized LTR database with prospective documentation of clinical information including comedication, laboratory and lung function results, outcomes and adverse events. Viral multiplex Polymerase Chain Reaction (PCR) results are available within 24-48 hours of sampling. LTRs call transplant coordinators 2 days after sampling to receive instructions about treatment modifications based on results.RESULTS: We included 133 patients with a total of 263 oseltamivir treatment episodes (87.4% as outpatients). Episode-based analyses provided the following key results: Median age 50.2 years, 30% and 70% received 75 and 150 mg/d, respectively, medication duration of oseltamivir treatment 4 days (range 2 to 67), 98.5% had concomitant antibiotic pharmacotherapy. Indications (>1 possible) for oseltamivir were: acute respiratory infection (67%), non-distinctive inflammatory reaction (51%), influenza-like illness (2.7%), other (18%). Influenza virus infection was confirmed by PCR diagnostics in only 7%. Rhinovirus was the most frequent pathogen detected (15%). We discovered a wide range of adverse events but none occurred in >5%, and most were mild and of questionable causal relationship to oseltamivir. None of the patients developed a respiratory infection with an unfavorable outcome.CONCLUSIONS: While controlled prospective studies are desirable but not available, this non-controlled retrospective analysis suggests that the preemptive use of oseltamivir for respiratory tract infections pending microbiological results is effective and safe.CLINICAL IMPLICATIONS: We recommend the preemptive use of oseltamivir in lung transplant recipients with suspected respiratory tract infection during the influenza season.DISCLOSURE: The following authors have nothing to disclose: Christoph Jungo, Stefan Russmann, Macé SchuurmansNo Product/Research Disclosure Information.
- Metapneumovirus Pneumonia in Young Adults.
Pathak V, Conterato A, Aris R Metapneumovirus Pneumonia in Young Adults. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):924A.Respiratory InfectionsSESSION TYPE: Original Investigation SlidePRESENTED ON: Tuesday, October 28, 2014 at 11:00 AM - 12:15 PMPURPOSE: The aim of this study was to describe the clinical characteristics of young adults with documented human Metapneumovirus (hMPV) infection at our institution.This retrospective analysis was done at University of North Carolina. Charts of patients who tested positive for hMPV by Luminex xTAG RVP assay from 1/1/2009 through 02/28/2014 were analyzed. Demographics, symptoms/signs, comorbidities, hospital course, treatment and disposition were recorded.RESULTS: Total 33 patients tested positive for hMPV during the study period. The incidence peaked in late winter and early spring. The mean age of these patients was 51+/- 21 (SD). There were 22 Caucasians, 7 African Americans and 4 Asians. The most common presenting symptoms in these patients were cough 24/33 (73%), dyspnea 20/33 (61%) and fever 20/33 (61%). Total 9/33 (27%) patients had underlying chronic lung disease. Seven patients (21%) had a history of malignancy and seven patients (21%) were on immunosuppressant medications. Mean FEV1 was 72% +/- 25 (SD) predicted in patients with chronic lung disease. On initial presentation chest radiographs revealed bilateral infiltrates in 11/33 (33%) unilateral infiltrate in 10/33 (30%) and no infiltrate in 12/33 (36%). Ten patients (30%) required ICU care, of which 7 were intubated. Five patients underwent bronchoscopy. Two patients had concomitant rhinovirus infection, one had concomitant adenovirus and one had influenza A. Two (6%) ICU patients died during their hospitalization. Total 30/33 patients in the study were treated with antibiotics and 15/33 received steroids. Four patients (12%) were treated with ribavirin. Five patients were empirically treated with oseltamivir.CONCLUSIONS: Human Metapneumovirus is a common pathogen which often presents with cough dyspnea and infiltrate on chest radiograph. Though adults hospitalized with hMPV often have multiple co-morbidities, previously healthy patients and younger adult patients still need to be considered for this illness.CLINICAL IMPLICATIONS: Human Metapneumovirus infections should be kept in differentials in patients presenting with cough, dyspnea and chest infiltrate. Among individuals requiring ICU care, high mortality is a concern.DISCLOSURE: The following authors have nothing to disclose: Vikas Pathak, Anna Conterato, Robert ArisNo Product/Research Disclosure Information.
- Viral Pneumonia in Patients With Community Acquired Pneumonia.
Abu Atherah E, Haj Ali E, Dias A, et al. Viral Pneumonia in Patients With Community Acquired Pneumonia. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):911A.Respiratory Infections Posters ISESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: To establish the prevalence of viral etiology in patients with community acquired pneumonia(CAP), and determine the most common viral pathogens causing CAP.METHODS: This is a retrospective cohort study. Patients admitted to the University of Louisville Hospital with CAP over a year were included.This study included 113 patients, of whom 52 (48%) were males. Thirty-three (29%) patients had a viral infection. The most common viral pathogen was influenza, which was detected in 16 (14%) patients. Co-infection with bacterial pathogens occurred in 10 (8.8%) patients, and co-infection with other viruses occurred in 11 (9.7%) patients. Four (3%) patients died in the hospital. The mean length of stay was 12.3 (SD = 6.9) days, and the mean time to clinical stability was 5.5 (SD = 3) days.CONCLUSIONS: The prevalence of viral etiology in patients admitted with CAP is high. Co-infection with bacterial pathogens and other viruses is also common. Influenza remains the most common viral etiology in these patients.CLINICAL IMPLICATIONS: This study will help identify the patient population at higher risk for CAP by knowing the risk factors. It will also identify the common viruses that cause CAP.and which viruses can cause severe CAP that needs to be admitted to the intensive care unit which can have prognostic value. It can also help guide the empiric antibiotic treatment by finding the common co-infecting bacteria.DISCLOSURE: The following authors have nothing to disclose: Emran Abu Atherah, Ehab Haj Ali, Ajoy Dias, Alan Jackson, Matthew Rayner-Lawren Woodford, Ishan Mehta, Michael Burk, Matthew Middaugh, Susan Elizabeth Dee, Timothy Lee Wiemken, Rodrigo Cavallazzi, Julio A RamirezNo Product/Research Disclosure Information.
- Use of a Dual Lumen Endobronchial Tube With a Bronchial Blocker to Treat Massive Hemoptysis.
Orellana-Barrios M, Yepes-Hurtado A, Huizar I Use of a Dual Lumen Endobronchial Tube With a Bronchial Blocker to Treat Massive Hemoptysis. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):779A.Bronchology/Interventional Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Isolation of the bleeding bronchial segments can aid in reducing flooding the rest of the airway and may tamponade the bleeding (1). We describe a case were the combination of a double lumen endotracheal (DLE, Size 37 F, Rüsch Bronchopart®, Duluth GA) and the Arnd® spherical bronchial blocker cuff (Cook Critical Care, Bloomington IN) were used simultaneously to isolate the bleeding lung segment.CASE PRESENTATION: A 65 year old male smoker with stage IV non-small cell lung cancer diagnosed one year previously was admitted to our Critical Care Unit for progressive shortness of breath, fever and cough. The patient was intubated due to respiratory failure, required vasopressor support and was treated with broad spectrum antibiotics for febrile neutropenia and oseltamivir for H1N1 influenza. On day 9 of his hospital stay, the patient developed massive hemoptysis and required increasingly higher ventilator parameters. Bronchoscopy was performed, demonstrating active bleeding from the right bronchus intermedius. The patient's Hg had dropped from initial value of 12.6 to 7.0 g/dL. In an attempt to control the hemoptysis and preserve as much of the non-bleeding airway, a DLE tube was introduced. With the aid of a pediatric fiberscope a concomitant bronchial blocker was introduced to the level of the bronchus intermedius to spare the patient's right upper lobe and optimize gas exchange (Fig#1).For the management of massive hemoptysis, both selective intubation of the affected lung and the use of the double lumen endotracheal tube have been described (2). The goal of these techniques is to protect non-bleeding lung from blood flood.CONCLUSIONS: In this case, we illustrate the feasibility of combining DLE intubation with endobronchial ballooning to further isolate the bleeding lung segments and maximize gas exchange. This can be particularly important in patients with poor lung reserve. Reference #1: Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med. 1994 Mar;15(1):147-67.Reference #2: Awad H, Malik O, Hollis K, et al. Bronchial blocker versus double-lumen tube for lung isolation with massive hemoptysis during cardiac surgery.J Cardiothorac Vasc Anesth. 2013 Jun;27(3):e26-8.The following authors have nothing to disclose: Menfil Orellana-Barrios, Andres Yepes-Hurtado, Isham HuizarNo Product/Research Disclosure Information.
- Successful Treatment of Postintubation Tracheal Stenosis With Balloon Dilation, AOC Electrocautery, and Application of Mitomycin C.
Fuller A, Sigler M, Kambali S, et al. Successful Treatment of Postintubation Tracheal Stenosis With Balloon Dilation, AOC Electrocautery, and Application of Mitomycin C. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):778A.Bronchology/Interventional Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Tracheal stenosis is a rare but known complication of endotracheal (ET) intubation. We present our experience of using balloon dilation (BD), Argon Plasma Coagulation (APC) endoscopic electrosurgery (EES) and application of Mitomycin C (MMC) as treatment for tracheal stenosis.CASE PRESENTATION: Case 1: 54 y/o woman was intubated for three days secondary to acute respiratory failure from acute asthma exacerbation and Influenza A. Four weeks later she presented with stridor. Bronchoscopy showed tracheal stenosis with diameter of 5mm. Rigid bronchoscopy and BD was performed followed by excision of granulation tissue with EEC. After successful dilation, topical MMC was applied at the site of granulation tissue. Post-procedure tracheal diameter was 1.2 cm with a lumen size >75% normal. Follow-up bronchoscopy revealed normal tracheobronchial tree. Case 2: 49 y/o woman was intubated for acute respiratory failure. She presented with stridor and significant dyspnea. Bronchoscopy was performed and revealed granulation tissue causing >50% tracheal stenosis. Rigid bronchoscopy, EEC, BD, APC and cryotherapy were then used to obtain >75% normal tracheal size. Topical MMC was then applied at the site of granulation tissue with resolution of the patient's symptoms. Case 3: 39 y/o woman had open tracheostomy after prolonged mechanical ventilation for acute stroke. A month later she developed respiratory distress. Bronchoscopy showed >90% narrowing of the trachea secondary to granulation tissue. The granulation tissue was debrided using cryotherapy and CRE balloon dilation. Repeat bronchoscopy three weeks later showed recurrence of granulation tissue which was again treated with cryotherapy and balloon dilatation. Topical mitomycin was applied at the site of granulation tissue. Patient presented 4 weeks later to ER with acute dyspnea secondary to recurrence of tracheal stenosis and died before any intervention could be done.Tracheal stenosis is a rare serious complication after intubation. Common treatments for this complication include: Nd:YAG laser, EES, APC electrocautery, balloon dilation, stenting, cryotherapy and surgical intervention. Surgery is a more definitive treatment but also carries significant higher risk involving complex procedure. Addition of topical MMC has recently been described as a potential addition to the treatment of tracheal stenosis. Our experience with 3 cases shows a good success (66%) with topical mitomycin application as definitive treatment for tracheal stenosis.CONCLUSIONS: The topical application of mitomycin following endoscopic electrosurgery can be used for successful treatment of post intubation tracheal stenosis. Reference #1: Simpson, C. Blake, and Joshua C. James. "The Efficacy of Mitomycin-C in the Treatment of Laryngotracheal Stenosis." The Laryngoscope 116.10 (2006): 1923-925. Online.DISCLOSURE: The following authors have nothing to disclose: Audra Fuller, Mark Sigler, Shrinivas Kambali, Raed AlalawiNo Product/Research Disclosure Information.
- Chronic Granulomatous Disease Complicated With Dissemination of BCG Vaccine.
Manonelles G, Martin V Chronic Granulomatous Disease Complicated With Dissemination of BCG Vaccine. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):688A.Pediatric Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Chronic granulomatous disease is caused by a deficiency of phagocyte microbicidal function, due to the inability to produce hydrogen peroxide and superoxide anion. The most common form is X-linked and presented with recurrent pulmonary infections.CASE PRESENTATION: A male patient a one year and nine months old, presented with febriles syndrome treated with multiple antibiotics such as clabulanic amoxicillin due to reoccurrent infection in the whole respiratory system; anemia, axillary adenopathy, without symptoms of recovery. For this reason he was referred to our hospital for diagnosis and treatment. At admission, his general condition was bad, with the following BM16.5 kg/m2, the patient is between 50-25 percentile growth. Presented: asthenia, decreased appetite, fever syndrome with records of 38 °, oxygen desaturation, with a 92 % to 21 % FiO2, respiratory rate of 36 per minute. Physical examination presented: right axillary lymphadenopathy, mobile, painless, hard elastic 1cm diameter, crepitant widespread rales and rhonchi in both lung fields and Other symptoms such as, increased rate of breathing, breathlessness and wheezing. Treatment was initiated with Clarithromycin and Amoxicillin clavulanic. TB empirical first-line treatment is added. He continued, febrile with records of 38-39 ° C, with antipyretics and physical means. Added access nonproductive cough and increased respiratory compromise adding retractions, and tachypnea. Background: Fully vaccinated. From month of life was treated for recurrent respiratory tract infections. Five months olds requiring hospitalization for acute pneumonia record. Laboratory results: anemia, increased erythrocyte sedimentation rate, hyperglycemia, and mild oxygen desaturation. Serological tests, toxoplasmosis, HIV, EBV, parvovirus, CMV, Mycoplasma, Bartonella, Brucella, Leptosipirosis, all negative. Dosage IgA and IgG slightly above its normal value, IgE 541.6 Ul/ml. Elevation of gamma globulin. DNA- antibody, ANCAs, and Rheumatoid Factor negative. Thorax CT: multiple images of lymph nodes in the mediastinum Observed in lung parenchyma patchy areas of airspace occupation distributed in both lungs and cavitated images in the lower lobes. Axillary lymphadenopathy. Upper abdomen no abnormalities. Normal Echocardiogram. Ocular Fundus, right eye net edges whitish lesions without macular involvement Faced with suspected diagnosis of TB specific studies are requested: Gastric Lavage, Lymph Node and Cerebrospinal Fluid: Negative smear and culture. Blood cultures for mycobacteria: Negatives. Tuberculin Skin Test: Negative.Were raised various differential diagnosis: Infectious diseases such as tuberculosis, toxoplasmosis, aspergillosis, staphylococci sepsis, tuberculosis being the entity that most compatible with the characteristics presented by the patient, although the bacillus was not found by the methods referred. Immunological diseases: Wiskott Aldrich immunodeficiency. Severe combined immunodeficiency disease is a group with deficiency of humoral and cellular immunity caused by various genetic mutations and associated enzyme deficiencies. The most common form is X-linked early onset in the first months of life, and is presented as severe mucocutaneous candidiasis, dissemination of BCG vaccine, persistent diarrhea, lung infections, meningitis, septicemia. Complement deficiency can start at different ages. C3 deficiencies present with sino-pulmonary infections by encapsulated bacteria, pneumococcus, Neisseria meningitidis, Haemophilus influenza. Autoimmune disease Systemic lupus erythematosus, polyangiitis, Wegener's granulomatosis.CONCLUSIONS: The patient remained febrile despite therapy instituted and showed no improvement in respiratory symptoms so it is referred to a specialist center for studies to detect diseases of the immune system. Resulting poor response in nitroblue tetrazolium (NBT) test, it was assumed as a chronic granulomatous disease complicated with dissemination of BCG (Bacille Calmette-Guerin) vaccine , given that the child was vaccinated at birth. Treatment was started with interferon gamma, TB drugs, Trimethoprim-sulfamethoxazole and Itraconazol, and showed significant improvement 40 days after starting treatment.Reference #1: Chronic granulomatous disease, Current Opinion in Immunology, Volume 15, October 2003, Pages 578-584, P G Heyworth, and col.DISCLOSURE: The following authors have nothing to disclose: Gabriela Manonelles, Vanina MartinNo Product/Research Disclosure Information.
- H1N1-Induced Organizing Pneumonia Mimicking Acute Respiratory Distress Syndrome.
Eliason F, Harden C, Mukherjee I H1N1-Induced Organizing Pneumonia Mimicking Acute Respiratory Distress Syndrome. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):309A.Critical Care Student/Resident Case Report Posters IIISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Organizing pneumonia (OP) is a reported complication of patients with H1N1 infection, typically after the interval development of acute respiratory distress syndrome (ARDS). Our patient, with recent history of H1N1 infection, was diagnosed as having OP by surgical lung biopsy (SLB) without the presence of pathologic features suggestive of ARDS.CASE PRESENTATION: A 49 year-old female with history of respiratory failure secondary to presumed ARDS in the setting of active H1N1 infection had a prolonged intubation, difficulty weaning from mechanical ventilation, and subsequent tracheostomy placement, in January of 2014. She had been treated with oseltamivir and a rapidly tapering dose of empiric steroids for peripheral infiltrates seen on CT scan of the chest. Her respiratory status improved thereafter and tracheostomy was subsequently decannulated. The patient was no longer hypoxic on room air and chest radiographs had almost completely normalized. A week following this, she started to become dyspneic with exertion. She presented to our Intensive Care Unit in March 2014 with rapidly evolving hypoxic respiratory failure with rising oxygen needs over the course of a week. Chest radiographs demonstrated evolving bilateral airspace disease and high resolution CT scan of the chest showed ground-glass opacities in all five lobes with associated traction bronchiectasis and fibrotic changes at the bases. Initial investigations for infectious etiologies, including H1N1 PCR and bacterial sputum culture were negative. Cardiogenic pulmonary edema was excluded with normal echocardiography, marginally elevated NT-proBNP and after aggressive diuresis did not improve oxygen requirements. Given the patient had no risk factors to suggest development of ARDS she underwent SLB. Specimens from the right upper, middle, and lower lobes showed OP without evidence of hyaline membranes or diffuse alveolar damage, typical of ARDS. The patient was placed on methylprednisolone with subsequent extubation and rapid improvement in both her respiratory symptoms and radiographic abnormalities.DISCUSSION: During both hospitalizations, the patient's clinical presentation and chest radiographs were suggestive of ARDS. However, given that SLB was diagnostic of OP without any pathologic features of ARDS, we believe that OP was the etiology of our patient's respiratory failure during both hospitalizations.CONCLUSIONS: We suggest that it is imperative to consider OP in the differential diagnosis of patients with H1N1 infection and hypoxic respiratory failure with bilateral airspace disease.Reference #1: Marchiori et al. Influenza A (H1N1) virus-associated pneumonia: High-resolution computed tomography-pathologic correlation. EJOR 80 (2011):500-504Reference #2: Cornejo et al. Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza. BMJ Case Reports 2010; 22 JulyReference #3: Kumar et al. H1N1-infected Patients in ICU and Their Clinical Outcome. N Am J Med Sci. (2012) Sep; 4(9):394-8DISCLOSURE: The following authors have nothing to disclose: Faith Eliason, Christopher Harden, Indrani MukherjeeNo Product/Research Disclosure Information.
- Chronic Q Fever: A Rare Case of Endocarditis and Embolism.
Sharma S, Wong J, Ivanovic A, et al. Chronic Q Fever: A Rare Case of Endocarditis and Embolism. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):308A.Critical Care Student/Resident Case Report Posters IIISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Coxiella burnetii is the cause of Q fever, a zoonotic illness resembling influenza with pneumonia or hepatitis. Chronic disease develops in 1-5% of patients months to years after infection. Chronic Q fever has been challenging to diagnose due to the non-specific presentation but can lead to severe complications including heart failure. We describe a case of chronic Q fever endocarditis with embolic complications.CASE PRESENTATION: A 57-year-old Latin American man presented with nausea, vomiting and headache and a three month history of fever, weight loss, and cough. Electrocardiogram showed a junctional escape rhythm. A prior chest radiograph showed pulmonary markings consistent with atypical pneumonia and a granuloma. MRI revealed a left superior cerebellar artery infarct with tonsillar migration for which the patient underwent placement of external ventricular drain and suboccipital decompression. Multiple laboratory abnormalities were noted including leukocytosis, thrombocytopenia, hyperbilirubinemia, elevated INR, cardiac enzymes and liver enzymes. Initial pan cultures were negative. Subsequent imaging revealed left femoral and bilateral gastric vein thrombosis that warranted heparin therapy and filter placement. The patient developed left hand and foot swelling which progressed to gangrenous changes. Echocardiography revealed an enlarged left ventricle with thrombus, left ventricular and right atrial filling defects, moderate mitral regurgitation, severe tricuspid regurgitation, and an ejection fraction of 20%. Serology revealed positive Q fever phase I IgM and phase II IgG titers. Treatment involved doxycycline and hydroxychloroquine.DISCUSSION: Chronic Q fever typically develops in patients with underlying valvular damage or immunocompromise. Endocarditis is the most common clinical manifestation and is often fatal without treatment. Here we describe a patient who presented with several features of Q fever with subsequent embolic stroke. He had no ascertainable epidemiological basis for infection but developed both infarction and cyanosis of embolic origin. Embolic phenomena are rare but have been reported in advanced disease. C burnetii is diagnosed through serology. Phase II antigens predominate in acute infection whereas elevated phase I IgG titers are characteristic of chronic disease. Follow-up after infection promotes early detection of progression to chronic disease.CONCLUSIONS: Delayed diagnosis of chronic Q fever results in significant morbidity and mortality. Therefore, the fitting clinical symptoms and serology must be pooled to form a diagnosis in cases where acute C burnetii remains undetected.Reference #1: Raoult D, Marrie T. Q fever. Clin Infect Dis 1995;20:489-95.Reference #2: Turck WP, Howitt G, Turnberg LA, et al. Chronic Q fever. Q J Med 1976;45:193-217.Reference #3: Anderson A, Bijlmer H, Fournier PE, et al. Diagnosis and management of Q fever - United States, 2013: Recommendations from CDC and the Q fever working group. MMWR Recomm Rep. 2013;62:1-30.DISCLOSURE: The following authors have nothing to disclose: Sharad Sharma, Jen Wong, Amy Ivanovic, Faraz Baig, Fariborz Rezai, Kristin Fless, Nirav Mistry, Frantz Pierre-Louis, Paul YodiceNo Product/Research Disclosure Information.
- Rhabdomyolysis Induced Renal Failure Secondary to Dual Infection With Influenza A and Legionella pneumophilia.
George Jacob A, George AM, John T Rhabdomyolysis Induced Renal Failure Secondary to Dual Infection With Influenza A and Legionella pneumophilia. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):281A.Critical Care Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Rhabdomyolysis is characterized by elevated creatine phosphokinase levels and can cause renal failure if not recognized promptly. Numerous precipatiting factors have been identified for this condition including injury, drug toxicity and infections. Here we report a case of severe rhabdomyolysis caused by dual infection with Influenza and Legionella. This case novel in the fact that both infectious agents are known to cause rhabdomylosis independantly however co-infection with both leading to rhabdomyolysis has not been reported earlier.CASE PRESENTATION: 47 year-old male presented with fever, sore throat, cough, myalgias and dark urine ongoing for the past 4 days. He denied any nausea, vomiting, diarrhea or recent trauma. Past medical history was unremarkable and he denied any medication use. On examination he was febrile(100.8F) and tachypneic. Air entry was decreased in the left lower lung zones along with crepitations. Lower extremity muscle groups were tender to palpation. Remainder of the examination was normal. Laboratory investigation showed leukocytosis with neutrophil predominance, elevated serum creatine(3.2mg/dl), increased blood urea nitrogen(60mg/dl) and markedly high levels of creatine phosphokinase(140,000IU/L). Urinanalysis showed presence of large amount of blood however red blood cell count was normal on microscopic examination. Urine myoglobin test was positive. Chest radiography demonstrated left lower lobe consolidation with mild effusion. Given clinical picture of rhabdomyolysis secondary to pneumonia an intensive infectious workup was initiated. Influenza viral swab and urine antigen for legionella both returned positive. Appropriate antibiotic therapy and aggressive fluid therapy was initiated. His respiratory status worsened the following day necessitating transfer to the intensive care unit for closer monitoring. Serum urea nitrogen and creatine levels continued to rise with declining urine output necessitating renal replacement therapy. Following two weeks of intensive theraepy his condition improved with near complete recovery of kidney function.DISCUSSION: Infections account for around 5% of rhabdomyolysis cases1. Though Legionnaire's disease is more common among the elderly population, rhabdomyolysis complicating pneumonia has been more commonly reported among younger males. It is usually from infection with serogroup 1. Bacterial endotoxin mediated muscle injury is thought to be responsible in such cases. Presence of severe uremia is recognized as a marker for increased morbidity and mortality in such patients. Among viral etiologies, influenza A is the most common agent associated with rhabdomyolysis2. Invitro studies have demonstrated viral invasion of muscle fibers as possible mechanism for muscle injury. Renal failure is more common among patients with influenza as compared to other infectious etiologies and is found to occur in around 50% of cases. Other possible bacterial, viral etiologies of rhabdomyolysis include streptococcus, shigella, salmonella, coxsackie virus and human immunodeficiency virus3. Though uncommon fungal and atypical parasitic infections can also cause elevated creatine phosphokinase levels, though not to the degree found with viral or bacterial infections. Management usually involves aggressive fluid therapy along with use of appropriate antimicrobial agents. Prognosis is usually good for lower levels of uremia and complete recovery of renal function is generally the norm. Our case is novel in the fact that it is the first one to demonstrate presence of both legionella and influenza infection in a patient with atraumatic rhabdomyolysis.CONCLUSIONS: Rhabdomyolysis in the setting of infection needs to be recognised early. Legionella and Influenza are the most common infectious agents associated with rhabdomyolysis and as demonstrated can occur concomitantly. Treatment consists of intravenous hydration and control of infection. Early recognition allows for prompt institution of appropriate therapy and helps to minimize renal complications associated with this disorderReference #1: Gabow PA et al. The spectrum of rhabdomyolysis.Medicine 1982; 61:141Reference #2: Foulkes W etal. Influenza A and rhabdomyolysis. J Infect 1990; 21:303Reference #3: Upinder S et al. Infectious etiologies of rhabdomyolysis: Three case reports and review. Clin Infect Dis 1996; 642: 9DISCLOSURE: The following authors have nothing to disclose: Amith George Jacob, Amrutha Mary George, Teny JohnNo Product/Research Disclosure Information.
- From Clean to Toxic: An Unusual Case of ARDS.
Osborne J From Clean to Toxic: An Unusual Case of ARDS. [JOURNAL ARTICLE]Chest 2014 Oct 1; 146(4_MeetingAbstracts):280A.Critical Care Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Acute respiratory distress syndrome (ARDS) is the onset of lung injury within 7 days of some defined event (trauma, infection, surgery, or reaction) with bilateral opacities that cannot be fully explained by cardiac failure or fluid overload. By defining the cause of ARDS, one can potentially lessen the effects and time course of the disease with treatment of the underlying cause. While infection or trauma is the traditional cause, solutions used for wound/ mouth care are often under identified as a potential toxin. The case of W demonstrates how the use of a common and seemingly innocent betadine solution caused severe respiratory injury and compromise.CASE PRESENTATION: W is a 47 year-old male with history of hypertension who presented after 2 weeks of influenza like illness. He quickly developed respiratory distress, hemoptysis, and airway compromise leading to emergent nasal intubation. Further investigation revealed history of recent tooth extraction with a CT scan showing probable necrotizing fasciitis of the retropharyngeal space. He received prompt and appropriate antibiotics, fluid, and vasopressors while awaiting surgical evaluation. On exam, W was nasally intubated in no distress and able to answer questions. His ABG at the time showed 7.402/39.7/60.1/24.2 on 40%. The only significant finding aside from fever was stridor despite the nasotracheal tube in place. W was taken to surgery for tracheostomy, neck washout and debridement revealing edematous tissue and dirty dishwater nonpurulent fluid in the retropharyngeal space. Drains were placed in the neck with plans for irrigation twice daily with betadine solution. Three days later, W had an acute respiratory decompensation from CPAP 60% to APRV 100%. W remained afebrile and normotensive during this time. ABG revealed new hypoxia 7.362/48/63/26.6. Chest radiograph demonstrated new bilateral infiltrates and on exam a frothy brown secretion from the tracheostomy had developed. While W was being treated with standard of care in the ICU including antibiotics and investigation of possible new sites of infection an answer could not be found. A hypothesis was presented that the betadine was somehow leaking into his tracheostomy which led to his respiratory distress. The irrigation was switched to saline and within 24 hours the patient showed drastic improvement in his ventilator requirements to PS 60% with ABG of 7.337/49.9/94.4/26.1. Antibiotics were narrowed to cover only group A streptococcus. Within 48 hours oxygen requirements were down to 40% FiO2 and an ABG of 7.425/39.1/91/25. Within 5 days he was on tracheostomy collar trials and by the end of the month was discharged from the hospital without a tracheostomy or supplemental oxygen.DISCUSSION: There is scant literature of betadine pulmonary toxicity leading to ARDS. While small in number, the evidence is quite striking to support a cause and effect relationship of topical toxicity. In the case reports found, the presentation occurred when the solution was used to clean/disinfect the mouth and throat in head-neck surgery. All cases had sudden increase in oxygen requirement after the solution was aspirated, an increased need of PEEP with difficulty ventilating, and CXR changes consistent with ARDS. The only research study performed on betadine and lung injury by Cheong Soon et al presented that the injuries could be reproduced and manipulated consistently by dose. On examination of rat lungs, there was macroscopic atelectasis, initial inflammation with edema, alveolar rupture and leukocyte infiltration into the interstitium leading to parenchyma loss and finally resolved with scar tissue.CONCLUSIONS: Betadine is under recognized as a toxic solution as it is so frequently used to sterilize tissues however there are risks with every step one takes in medicine. Unlikely sources of disease are still possible in the art of medicine and as one broadens the possibilities a once unanswerable question becomes easily explained. For W, this theory of betadine pulmonary toxicity became reality and his life and lungs were spared.Reference #1: Cheong Soon et al. Lung injury induced by the pulmonary instillation of providone-iodine in rats. J anesthesia (2012) 26:70-79Reference #2: Tae Hun An, Byung Ryang Ahn. Pneumonia due to aspiration of povidine iodine after induction of general anesthesia. Korean J Anesthesiology 2011. September 61(3): 251-256Reference #3: Chepla Kyle, Gosain Arun. Interstitial pneumonitis after betadine aspiration. The journal of craniofacial surgery 23(6). November 2012DISCLOSURE: The following authors have nothing to disclose: Jennifer OsborneNo Product/Research Disclosure Information.