Emma Hitt, PhD
May 20, 2009 — A report describing 30 novel H1N1 influenza case patients, hospitalized from April 20 to May 17 in California, indicates no deaths as of yet, but describes a range of disease, including severe and prolonged complications.
The report, in the Morbidity and Mortality Weekly Report (MMWR) from the Centers for Disease Control and Prevention (CDC) issued on Monday, also includes a detailed description of 4 of the 30 cases.
Anne Schuchat, MD, the interim deputy director for Science and Public Health Program and director of the CDC's National Center for Immunization and Respiratory Diseases, described the report’s findings at yesterday’s CDC media briefing.
“The detailed descriptions of 4 cases...illustrate the spectrum of illness that we’re seeing with this virus,” Dr. Schuchat said. “Even among hospitalized cases, there seems to be a range of severity from relatively short hospitalizations to longer, much more complicated hospitalizations,” she said.
The most common diagnoses for the patients upon admission were pneumonia and dehydration. Of the patients, 64% had underlying medical conditions, the most common being lung disease (eg, chronic obstructive pulmonary disease and asthma). Patients also had immunosuppressive conditions, chronic heart disease, diabetes, and obesity.
Typical symptoms reported among patients included fever (97%), cough (77%), vomiting (46%), and shortness of breath (43%). Diarrhea was present in only 3 patients (10%).
Of the 30 patients, 25 underwent chest X-ray. Of those, 15 patients (60%) had abnormalities indicative of pneumonia, including 10 with multilobar infiltrates and 5 with unilobar infiltrates; 4 patients required mechanical ven¬tilation.
Five of the patients were pregnant, and 2 of these women developed complications, including spontaneous abortion and premature rupture of the membranes, which resulted in termination of the pregnancies at 13 and 35 weeks of gestation, respectively.
“The role that preceding infection with novel influenza A (H1N1) played in these outcomes is unclear,” according to an editorial note in the MMWR report.
No evidence of secondary bacterial infection was present in any of the patients.
Half of the patients received antiviral treatment with oseltamivir, with one third of those receiving treatment within 48 hours of symptom onset.
As of May 17, according to the report, 7 patients remain hospitalized with a median length of stay of 15 days. The rest of the patients were discharged home with a median length of hospital stay of 4 days (range, 1 – 10 days).
The report also describes 4 of the hospitalized cases in detail. One was a 5-month-old female infant who was in the hospital recovering from neonatal complications and was diagnosed with opacification of both lung fields upon X-ray at day 150 of her hospital stay. The infant remains hospitalized in critical condition.
Another case report describes a previously healthy, 29-year-old woman who was 28 weeks pregnant. Although she was not treated with antiviral medications, the patient gradually improved and was discharged on amoxicillin after 9 days.
During the press conference, Dr. Schuchat noted that pregnancy is a risk factor for worse complications from influenza due to immunosuppression. “We think it’s important to treat with antiviral drugs — sometimes doctors are worried about using medicines during pregnancy,” she told Medscape Infectious Diseases, but she added that “use of one of the antiviral drugs is probably appropriate in treating such women.”
A third case involved a 32-year-old man with a history of obstructive sleep apnea who sought care after a 3-day history of fever, chills, and productive cough. After a course of broad spectrum antibiotics, the man improved and was discharged on hospital day 10.
The fourth patient described was an 87-year-old woman with multiple medical problems, including recently diagnosed breast cancer. The patient was brought in after being found unconscious and remains hospitalized in critical condition under intensive care.
The report, authored by the California Department of Public Health, notes that false-positive and false-negative results may be common for the rapid antigen test and are recommending that clinicians collect respiratory specimens for real-time reverse transcription–polymerase chain reaction "testing, subtyping, and further characterization at public health laboratories from patients who are hospitalized or who die with febrile respiratory illness.”
Morb Mortal Wkly Rep. Published online May 18, 2009.
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