A case of novel swine influenza A (H1N1) pneumonia complicated with virus-associated hemophagocytic syndrome

Diagnostic difficulties of AH1N1 influenza infection in children with acute lymphoblastic leukemia: Two case reports

INTRODUCTION

Children with acute lymphoblastic leukemia (ALL) are at a risk of developing influenza-related complications. Approximately 10% of influenza-infected children with ALL or other types of cancer need intensive care, and 5% of them eventually die.

PATIENTS' CONCERNS

We report 2 children with ALL and the swine-origin influenza A virus infection. Diagnosing influenza in them was a challenge. Medical records of these children were reviewed for demographic, clinical, and laboratory data. Patients were hospitalized in the Department of Pediatric Hematology, Oncology, and Transplantology of the Medical University of Lublin, Poland. Case 1 involved a 2-year-old girl who, according to acute lymphoblastic leukemia intercontinental Berlin-Frankfürt-Münster protocol 2009, started chemotherapy in July 2015. She was categorized in the intermediate risk group and received the induction and consolidation phase of the therapy without severe complications. The reinduction therapy was administered in the outpatient department till the 15 day. On the 20 day of this phase, she was admitted to our department with fever, mucositis, tachypnea, abdominal pain, and diarrhea. In September 2009, a 14-year-old boy (case 2) who, according to acute lymphoblastic leukemia intercontinental Berlin-Frankfürt-Münster protocol 2002, was categorized in the high-risk (HR) group, received the induction (Protocol I) phase of therapy without severe complications. On the 7 day of the HR-1 course, he manifested fever and strong, tiring cough, followed by strong mucositis. Chemotherapy had to be interrupted in both children.

DIAGNOSIS

Respiratory viral infections, causing pneumonia, occurred in both patients during anticancer treatment. Initially, the real-time polymerase chain reaction test for the swine-origin influenza A was negative in both patients, which delayed the diagnosis. Additionally, bacterial, and fungal complications were also observed.

INTERVENTIONS

Both patients received oseltamivir twice a day, a broad-spectrum antibiotic, antifungal drug, and granulocyte colony growth factor.

OUTCOMES

The disease progressed quickly, and our patients subsequently died.

CONCLUSION

We speculated that early antiviral treatment can help in the better management of patients in the HR group. It is also important to minimize influenza morbidity and mortality by vaccinating family members, using empiric therapy, providing immediate antiviral therapy, and educating parents about hygiene measures.

Impact of severe hematological abnormalities in the outcome of hospitalized patients with influenza virus infection

Although hematological abnormalities have been described among patients with influenza virus infection, little is known about their impact on the outcome of the patients. The aim of this study was to assess the frequency and clinical impact of severe hematological abnormalities in patients with confirmed influenza virus infection. This was an observational retrospective study including all adult patients with diagnosis of influenza virus infection hospitalized from January to May 2016 in our institution. Influenza virus infection was diagnosed by means of rRT-PCR assay performed on respiratory samples. Poor outcome was defined as a composite endpoint in which at least one of the following criteria had to be fulfilled: (a) respiratory failure, (b) SOFA ≥2, or (c) death. Two hundred thirty-nine patients were included. Applying the HLH-04 criteria for the diagnosis of hemophagocytic syndrome, cytopenias (hemoglobin ≤9 g/dl, platelets <100,000/μl or neutrophils <1,000/μl) were present in 51 patients (21%). Patients with hematological abnormalities showed higher SOFA scores, respiratory failure, septic shock and in-hospital mortality than the remaining patients. The composite endpoint was present in 33.3% in the cytopenias group vs. 13.3% in the group without cytopenias (p=0.001). In a multivariate analysis, variables associated with the composite endpoint were: use of steroids prior to present admission (OR: 0.12; 95% CI: 0.015–0.96, p=0.046), presence of any hematological abnormality (OR: 3.54; 95% CI:1.66–7.51, p= 0.001), and LDH>225 U/l (OR:4.45; CI:1–19.71, p=0.049). Hematological abnormalities are not uncommon among hospitalized patients with influenza virus infection, and they are associated with a poorer outcome.

Report of a Fatal Pediatric Case of Hemophagocytic Lymphohistiocytosis Associated with Pandemic Influenza A (H1N1) Infection in 2009

An acute viral infection may lead to death, as seen in the recent novel 2009 influenza A (H1N1) virus pandemic that rapidly spread worldwide. Hemophagocytic lymphohistiocytosis (HLH) is a systemic disorder with high mortality rates and can be triggered by various etiological agents, including viral infections. H1N1-associated HLH is a very rare condition that may cause extremely severe complications leading to multiple organ failure (MOF) and death. We report an unusual case of a rapidly progressive and fatal H1N1 infection that was complicated with HLH and MOF in a previously healthy 8-year-old Asian female who initially presented with fever and abdominal pain. To enable early recognition and proper treatment, physicians should be aware of the possibility of this fatal complication, which may present with unusual initial symptoms.

Prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis

OBJECTIVE

To describe the prognostic factors and outcomes of adults with hemophagocytic lymphohistiocytosis (HLH), a rare disorder caused by pathologic activation of the immune system.

PATIENTS AND METHODS

The study population consisted of a consecutive cohort of adult (age ≥18 years) patients treated at Mayo Clinic in Rochester, Minnesota, from January 1, 1996, through December 31, 2011, in whom a diagnosis of HLH was suspected and subsequently confirmed by retrospective review using the HLH-04 diagnostic criteria.

RESULTS

Of 250 adult patients suspected of having HLH, 62 met the HLH-04 diagnostic criteria and were included in the final analysis. The median age was 49 years (range, 18-87 years), and 42 (68%) were male. The underlying cause of HLH was malignant tumor in 32 patients (52%), infection in 21 patients (34%), autoimmune disorder in 5 patients (8%), and idiopathic disease in 4 patients (6%). After a median follow-up of 42 months, 41 patients (66%) had died. The median overall survival of the entire cohort was 2.1 months. The median overall survival of patients with tumor-associated HLH was 1.4 months compared with 22.8 months for patients with non-tumor-associated HLH (P=.01). The presence of a malignant tumor and hypoalbuminemia were significant predictors of inferior survival on multivariate analysis.

CONCLUSION

In this large series of adults with secondary HLH treated at a single tertiary care center, patients with low serum albumin levels and tumor-associated HLH had a markedly worse survival. Hemophagocytic lymphohistiocytosis remains elusive and challenging to clinicians who must maintain a high index of suspicion. The recent discovery of several novel diagnostic and therapeutic modalities may improve outcomes of adult patients with HLH.

Discrepancy of in-vitro data and clinical efficacy of micafungin against Candida tropicalis endophthalmitis

We report findings for a 74-year-old woman with Candida tropicalis endophthalmitis for whom an increase in b-D-glucan level and worsening of endophthalmitis were observed after intravenous injection of micafungin, an echinocandin antifungal agent. Endogenous endophthalmitis caused by C. tropicalis developed in both eyes. On the basis of her surgical history, laboratory data,and lesions, tentative diagnosis of fungal endophthalmitis was made. She was then treated with fluconazole and itraconazole, but the b-D-glucan level did not decrease, and there was no improvement of the endophthalmitis. The fluconazole was discontinued and replaced by micafungin.Unexpectedly, the level of b-D-glucan increased and endophthalmitis did not improve. The micafungin was immediately stopped and replaced by intravenous fluconazole with amphotericin B syrup, but the itraconazole was continued. Marked resolution of the vitreous inflammation was observed in both eyes, and the serum b-D-glucan level was reduced. Because active macular infiltrates were observed in the right eye, vitrectomy was performed. The micafungin minimum inhibitory concentration against the C. tropicalis strain isolated from our patient was 0.03 lg/ml. This paradoxical effect of micafungin should be remembered, and b-D-glucan level should be frequently monitored after intravenous injection of micafungin.