Clinical Effects of Influenza – Bad things can Happen Lou Irving Director Respiratory and Sleep Medicine RMH Director Clinical Training RMH Visiting Physician PeterMac Case 1 • • 42 yo mother of 2 young children, both with URTIs Past history - epilepsy (stable), non smoker. Not vaccinated • Presents to ED with 4 days of fever, myalgia, lethargy, sore throat and nonproductive cough • Examination HR 120 BP, 100/60, SaO2 98%on 60% O2 via CPAP • Bilateral bronchial breathing • • • WBC 7.5, CRP 81, Cr 42 pH 7.41, PaCO2 31 PaO2 53 RA pH 7.39 PaCO2 33 PaO2 94 (FiO2 60%) CTPA in ED at time of presentation. Day 4 Bilateral dense consolidation Case1 – Transferred to ICU and Isolated Positive Flu B PCR on throat swab All cultures negative Pneumococcal serology / urinary Ag neg Treated with oseltamivir Day 2 of admission iv antibiotics NIV and high flow O2 brief ionotropic support Discharged day 6 Off supplemental O2, CRP 15 Reviewed OPD 1 week later - well 1 week post discharge Case 1 - Issues • Likely primary viral pneumonia / ARDS Case 2 • • • • 73 yo mother of Case 1 - living with family Past history – coronary a disease, left ventricular failure Current smoker, severe COPD (FEV1 0.5 L). Last admission 2yo 2 glasses alcohol a day. Current influenza vaccination • Presented to ED with fever, SOB, leg weakness, urinary and faecal incontinence • Examination confused, HR 126, SaO2 88%, reduced breath sounds, left basal crepitations, no focal neurological signs • • • • Throat swab Flu B PCR positive Hb 90, WBC 12,000, CRP 264, Cr 52 pH 7.43, PaCO2 35, PaO2 55 (RA) Blood cultures neg, no sputum Case 2 – Isolated in Ward • Treated for influenza, pneumonia and AECOPD oseltamivir iv ceftriaxone and azithramycin then oral amoxycillin and doxycyclin prednisalone inhaled bronchodilators smoking cessation vitamin D • 14 day admission Case 2 – Readmission 9 days later • Presented with 2 days of coryzal symptoms and increased breathlessness • Evidence of 1. mild non-bacterial exacerbation of COPD 2. Non STEMI new ECG changes, raised troponins, normal coronary angiogram • Discharged after 8 days Case 2 – Issues • Influenza B despite of vaccination - poor health status and impaired immune responses - ? value of second dose • Precipitant of - exacerbation of COPD - pneumonia - ischaemic heart disease - prolonged and recurrent hospital admissions Case 3 • • • 38 yo previously well. No Fuvax Presented to ED with 6 day flu-like illness after young son developed flu On oseltamivir for 6 days from GP – no improvement • Examination temp 39°C, RR 50, SaO2 86%, confused, GCS 14, reduced breath sounds right base • pH 7.39, PaCO2 32, PaO2 Creatinine144, • Intubated in ED transferred to ICU • • Flu PCR neg Blood cultures positive Strep pneumoniae Case 3 - Progress Treatment Broad spectrum antibiotics incl staph cover Steroids Invasive ventilatory and ionotropic support Remained febrile. Unable to be extubated CT showed pleural effusion. Tap revealed pus VATS drainage day 6 Slow recovery VAP (Klebsiella) Extubated day 11 Discharged to rehabilitation day 20 Case 3 - Progress Inpatient rehabilitation for 1 week Now at home Issues When is influenza more than simple flu Consequences of secondary bacerial pneumonia in otherwise normal host Case 4 – Long Term Effects CT of chest of previously well 26 yo female 6 months following severe pandemic influenza when she was pregnant. She required invasive ventilatory support for 5 days. The CT shows severe lung damage with bullous formation Effect of influenza on respiratory epithelium Before infection After infection Scanning Electron Micrograph Nicholson 1999 Long-term impairment of TLR5-dependent neutrophil recruitment after resolution of an influenza infection Didierlaurent A. et.al. Journal of Experimental Medicine 2008:205:323-329 © 2008 Didierlaurent et.al.
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