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Abstract
Whenever the cardinal manifestations of a disorder occur in similar disorders, there is potential for a disease mimic. Legionnaire's disease has protean manifestations and has the potential to mimic or be mimicked by other community acquired pneumonias (CAPs). In CAPs caused by other than Legionella species, the more characteristic features in common with legionnaire's disease the more difficult the diagnostic conundrum. In hospitalized adults with CAP, legionnaire's disease may mimic influenza or other viral pneumonias. Of the bacterial causes of CAP, psittacosis and Q fever, but not tularemia, are frequent mimics of legionnaire's disease.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, 222 Station Plaza North, #432, Mineola, NY 11501, USA; School of Medicine, State University of New York, Stony Brook, NY, USA.
| | - Cheston B Cunha
- Division of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA
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Are atypical lymphocytes present with viral influenza-like illnesses (ILIs) in hospitalized adults? Eur J Clin Microbiol Infect Dis 2016; 35:1399-401. [PMID: 27250631 DOI: 10.1007/s10096-016-2675-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
The purpose of this investigation was to determine if atypical lymphocytes were of diagnostic value in viral influenza-like illnesses (ILIs) in hospitalized adults during the influenza season. Are atypical lymphocytes present with viral ILIs in hospitalized adults? During the influenza season, hospitals are inundated with influenza and viral ILIs, e.g., human parainfluenza virus-3 (HPIV-3). Without specific testing, clinically, it is difficult to differentiate influenza from ILIs, and surrogate influenza markers have been used for this purpose, e.g., relative lymphopenia. The diagnostic significance of atypical lymphocytes with ILIs is not known. We retrospectively reviewed the charts of 35 adults admitted with pneumonia due to viral ILI. The diagnosis of 14 patients was by respiratory virus polymerase chain reaction (PCR). During the 2015 influenza A season with ILIs, atypical lymphocytes were not present in influenza A (H3N2) patients but atypical lymphocytes were present in some ILIs, particularly HPIV-3. With viral ILIs, atypical lymphocytes should suggest a non-influenza viral diagnosis.
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Cunha BA, Mickail N, Thekkel V. Unexplained Increased Incidence of Legionnaires Disease during the “Herald
Wave” of the H1N1 Influenza Pandemic. Infect Control Hosp Epidemiol 2015; 31:562-3. [DOI: 10.1086/652453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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4
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Cunha BA, Syed U, Thekkel V, Davis M. Unusual Nosocomial Exposure to HINI Influenza Virus via Open-Chest Cardiac Massage. Infect Control Hosp Epidemiol 2015; 31:775-6. [DOI: 10.1086/653817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cunha BA, Connolly JJ, Abruzzo E. Clinical implications of dual-positive rapid influenza diagnostic tests during influenza season: Co-colonization, coinfection, or false positive test? Am J Infect Control 2014; 42:1139-40. [PMID: 25278415 DOI: 10.1016/j.ajic.2014.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 06/19/2014] [Accepted: 06/19/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Infection Control Department, Winthrop-University Hospital, Mineola, NY; School of Medicine, State University of New York, Stony Brook, NY.
| | - James J Connolly
- Infectious Disease Division, Infection Control Department, Winthrop-University Hospital, Mineola, NY; School of Medicine, State University of New York, Stony Brook, NY
| | - Eileen Abruzzo
- Infectious Disease Division, Infection Control Department, Winthrop-University Hospital, Mineola, NY; School of Medicine, State University of New York, Stony Brook, NY
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Asai N, Ohkuni Y, Kaneko N, Kawamura Y, Aoshima M. A successfully treated case of parainfluenza virus 3 pneumonia mimicking influenza pneumonia. J Bras Pneumol 2013; 38:810-2. [PMID: 23288130 DOI: 10.1590/s1806-37132012000600020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Lee JE, Choe KW, Lee SW. Clinical and radiological characteristics of 2009 H1N1 influenza associated pneumonia in young male adults. Yonsei Med J 2013; 54:927-34. [PMID: 23709428 PMCID: PMC3663245 DOI: 10.3349/ymj.2013.54.4.927] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Pneumonia was an important cause of death in 2009 H1N1 influenza pandemic (pH1N1). Clinical characteristics of pH1N1 have been described well, but discriminative characteristics suggesting pH1N1 infection in pneumonia patients are not evident today. We evaluated differences between clinical and radiologic characteristics for those associated and not associated with pH1N1 influenza during the pandemic period. MATERIALS AND METHODS We reviewed all patients with pneumonia who visited the Armed Forces Capital Hospital between July 2009 and February 2010. During this period, all pneumonia patients were tested for pH1N1 by reverse transcription-polymerase chain reaction (RT-PCR) using nasopharyngeal specimens. RESULTS In total, 98 patients with pneumonia were enrolled. Their median age was 20 years and all patients were males. Forty-nine (50%) of patients had pH1N1 infection and the others (50%) had negative results in pH1N1 RT-PCR. Patients with pH1N1 infection complained of dyspnea more commonly (83.3% vs. 29.0%; p<0.001), had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores [5 (range, 0-12) vs. 3 (range, 0-11); p<0.01], fewer days of prehospital illness [2 (range, 0-10) vs. 4 (range, 0-14); p=0.001], and a higher chance of bilateral infiltrates on chest X-ray (CXR) (67.3% vs. 14.3%; p<0.001) and ground-glass opacity (GGO) lesions on computed tomography (CT; 48.9% vs. 22.0%; p<0.001) than patients without pH1N1 infection. CONCLUSION Dyspnea, bilateral infiltrates on CXR, and GGO on CT were dominant features in pH1N1-associated pneumonia. Understanding these characteristics can help selection of patients who require prompt antiviral therapy.
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MESH Headings
- Adolescent
- Adult
- Antiviral Agents/therapeutic use
- Dyspnea/virology
- Humans
- Influenza A Virus, H1N1 Subtype/genetics
- Influenza A Virus, H1N1 Subtype/pathogenicity
- Influenza, Human/complications
- Influenza, Human/diagnostic imaging
- Influenza, Human/virology
- Male
- Middle Aged
- Pneumonia/diagnostic imaging
- Pneumonia/etiology
- Pneumonia, Viral/diagnostic imaging
- Pneumonia, Viral/drug therapy
- Pneumonia, Viral/etiology
- Pneumonia, Viral/virology
- Radiography, Thoracic
- Tomography, X-Ray Computed
- Young Adult
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Affiliation(s)
- Ji Eun Lee
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Kang-Won Choe
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Respiratory syncytial virus (RSV) community-acquired pneumonia (CAP) in a hospitalized adult with human immunodeficiency virus (HIV) mimicking influenza A and Pneumocystis (carinii) jiroveci pneumonia (PCP). Heart Lung 2011; 41:76-82. [PMID: 22005289 DOI: 10.1016/j.hrtlng.2011.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infections in young children, the elderly, and immunocompromised hosts, but RSV is a rare cause of community-acquired pneumonia (CAP) in hospitalized adults with human immunodeficiency virus (HIV). In patients with HIV, CAP is most frequently attributable to the usual bacterial respiratory pathogens that cause CAP in immunocompetent hosts, eg, Streptococcuspneumoniae or Hemophilus influenzae. Adults with HIV are also predisposed to intracellular CAP pathogens, ie, Mycoplasmatuberculosis, Salmonella spp., Pneumocystis (carinii) jiroveci (PCP), cytomegalovirus, and Legionella spp. This year, co-circulating in the community during influenza season were strains of human seasonal influenza A (H3N2) and swine influenza A (H1N1). During the influenza season, in adults hospitalized with HIV, the diagnostic possibilities should include influenza-like illnesses, eg, human parainfluenza virus types 3 and 4, human metapneumovirus, and pertussis. CASE REPORT We present an adult with HIV, hospitalized for an influenza-like illness during influenza season. The differential diagnosis of CAP in this patient included influenza A and PCP. CONCLUSION We report on an adult patient with HIV with CAP that mimicked influenza and PCP, and was attributable to RSV.
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Cunha BA, Hage JE, Thekkel V. Infection control implications of influenza A and influenza B: coinfection or cocirculating strains? Am J Infect Control 2011; 39:701-702. [PMID: 21741728 DOI: 10.1016/j.ajic.2011.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 03/21/2011] [Indexed: 11/15/2022]
MESH Headings
- Aged, 80 and over
- Child
- Child, Preschool
- Coinfection/virology
- Diagnostic Errors
- Fluorescent Antibody Technique
- Hospitalization
- Humans
- Infection Control/methods
- Influenza A Virus, H1N1 Subtype/genetics
- Influenza A Virus, H1N1 Subtype/immunology
- Influenza A Virus, H1N1 Subtype/isolation & purification
- Influenza A Virus, H3N2 Subtype/genetics
- Influenza A Virus, H3N2 Subtype/immunology
- Influenza A Virus, H3N2 Subtype/isolation & purification
- Influenza B virus/genetics
- Influenza B virus/immunology
- Influenza B virus/isolation & purification
- Influenza, Human/diagnosis
- Influenza, Human/physiopathology
- Influenza, Human/virology
- Male
- Polymerase Chain Reaction/methods
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Infection Control Section, Winthrop-University Hospital, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York
| | - Jean E Hage
- Infectious Disease Division, Infection Control Section, Winthrop-University Hospital, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York
| | - Valsamma Thekkel
- Infectious Disease Division, Infection Control Section, Winthrop-University Hospital, Mineola, New York, and State University of New York School of Medicine, Stony Brook, New York
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Hage JE, Petelin A, Cunha BA. Before influenza tests results are available, can droplet precautions be instituted if influenza is suggested by leukopenia, relative lymphopenia, or thrombocytopenia? Am J Infect Control 2011; 39:619-21. [PMID: 21636171 DOI: 10.1016/j.ajic.2011.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/11/2011] [Indexed: 11/24/2022]
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Fulminant fatal swine influenza (H1N1): Myocarditis, myocardial infarction, or severe influenza pneumonia? Heart Lung 2011; 39:453-8. [PMID: 20831976 DOI: 10.1016/j.hrtlng.2010.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/14/2010] [Indexed: 11/20/2022]
Abstract
The swine influenza (H1N1) pandemic began in Mexico and rapidly spread worldwide. As is the case with pandemic influenza A, the majority of early deaths have been in young healthy adults. The complications of pandemic H1N1 have been reported from several centers. Noteworthy has been the relative rarity of bacterial coinfection in bacterial pneumonia in hospitalized adults with H1N1 pneumonia. Simultaneous bacterial community-acquired pneumonia due to methicillin-sensitive Staphylococcus aureus or community-acquired methicillin resistant S. aureus and subsequent bacterial community-acquired pneumonia due to S. pneumoniae or Haemophilus influenzae have been reportedly rare (0.4%-4% of well-documented cases). Cardiac complications of H1N1 infection have been uncommon. Young healthy adults without a cardiac history who have H1N1 and chest pain usually have either acute myocardial infarction or acute myocarditis. Cardiac symptomatology with H1N1 often overshadows pulmonary manifestations, that is, influenza pneumonia. With H1N1 pneumonia, clinicians should be alert for otherwise unexplained tachycardia or chest pain that may represent acute myocardial infarction or myocarditis. We present a case of rapidly fatal H1N1 in a young adult treated with oseltamivir and peramivir. He was initially tachycardic, thought to represent myocarditis. He subsequently became hypotensive and expired. At autopsy there was cardiomegaly present but there were no signs of acute myocardial infarction or myocarditis. Pathologically, he died of severe H1N1 pneumonia and not bacterial pneumonia.
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Cunha BA, Mickail N, Syed U, Strollo S, Laguerre M. Rapid clinical diagnosis of Legionnaires' disease during the "herald wave" of the swine influenza (H1N1) pandemic: the Legionnaires' disease triad. Heart Lung 2011; 39:249-59. [PMID: 20457348 PMCID: PMC7112664 DOI: 10.1016/j.hrtlng.2009.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/21/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND In adults hospitalized with atypical community-acquired pneumonia (CAP), Legionnaires' disease is not uncommon. Legionnaire's disease can be differentiated from typical CAPs and from other atypical CAPs based on its characteristic pattern of extrapulmonary organ involvement. The first clinically useful diagnostic weighted point score system for the clinical diagnosis of Legionnaires' disease was developed by the Infectious Disease Division at Winthrop-University Hospital in the 1980s. It has proven to be diagnostically accurate and useful for more than two decades, but was time-consuming. Because Legionella spp. diagnostic tests are time-dependent and problematic, a need was perceived for a rapid, simple way to render a clinical, syndromic diagnosis of Legionnaires' disease pending Legionella test results. During the "herald wave" of the swine influenza (H1N1) pandemic in the New York area, our hospital, like others, was inundated with patients who presented to the Emergency Department with influenza-like illnesses (ILIs) for H1N1 testing/evaluation. Most patients with ILIs did not have swine influenza. Hospitalized patients with ILIs who tested positive with rapid influenza diagnostic tests (RIDTs) were placed on influenza precautions and treated with oseltamivir. Unfortunately, approximately 30% of adult patients admitted with an ILI had negative RIDTs. Because the definitive laboratory diagnosis of H1N1 pneumonia by reverse transcription-polymerase chain reaction(RT-PCR), testing was restricted by health departments, resulted in clinical and infection control dilemmas in determining which RIDT-negative patients did, in fact, have H1N1 pneumonia. OBJECTIVE Accordingly, a diagnostic weighted point score system was developed for H1N1 pneumonia patients, based on RT-PCR positivity by the Infectious Disease Division at Winthrop-University Hospital. This diagnostic point score system for hospitalized adults with negative RIDTs was time-consuming. As the pandemic progressed, a simplified diagnostic swine influenza (H1N1) triad was developed for the rapid clinical diagnosis of probable H1N1 pneumonia, which also differentiated it from its mimics as well as from bacterial pneumonia, eg, Legionnaires' disease. During the "herald wave" of the H1N1 pandemic, we noticed an unexplained increase in Legionnaires' disease CAPs. Because clinical resources were stressed to the maximum during the pandemic, it was critically important to rapidly identify patients rapidly with Legionnaire's disease who did not require influenza precautions or oseltamivir, but who did require anti-Legionella antimicrobial therapy. METHODS Based on the Winthrop-University Hospital Infectious Disease Division's diagnostic weighted point score system for Legionnaires' disease (modified), key indicators were identified and became the basis for the diagnostic Legionnaires' disease triad. The diagnostic Legionnaires' disease triad was used to make a clinical diagnosis of Legionnaires' disease until the results of Legionella diagnostic tests were reported. The diagnostic Legionnaires' disease triad diagnosed Legionnaires' disease in hospitalized adults with CAPs with extrapulmonary findings (atypical CAP) and relative bradycardia, accompanied by any three (ie, a triad) of the following: otherwise unexplained relative lymphopenia, early/mildly elevated serum transaminases (SGOT/SGPT), highly increased ferritin levels (> or =2 x n), or hypophosphatemia. The diagnostic Legionnaires' disease triad provides clinicians with a rapid way to clinically diagnose Legionnaires' disease, pending Legionella test results. RESULTS The accuracy of the diagnostic Legionnaires' disease triad was confirmed in our 9 cases of Legionnaires' disease by subsequent Legionella diagnostic testing. CONCLUSIONS The diagnostic Legionnaires' disease triad is particularly useful in situations where a rapid clinical syndromic diagnosis is needed, ie, during an H1N1 pandemic.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA
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Severe swine influenza A (H1N1) versus severe human seasonal influenza A (H3N2): Clinical comparisons. Heart Lung 2011; 40:257-61. [DOI: 10.1016/j.hrtlng.2010.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 06/17/2010] [Indexed: 11/20/2022]
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14
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Swine influenza (H1N1) pneumonia in hospitalized adults: Chest film findings. Heart Lung 2011; 40:253-6. [DOI: 10.1016/j.hrtlng.2010.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 07/19/2010] [Indexed: 11/21/2022]
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Systemic lupus erythematosus (SLE) pneumonitis mimicking swine influenza pneumonia during the swine influenza (H1N1) pandemic. Heart Lung 2011; 40:462-6. [PMID: 21453970 DOI: 10.1016/j.hrtlng.2010.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 07/17/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND We present a young woman with a negative medical history who presented with acute systemic lupus erythematosus (SLE) pneumonitis mimicking swine influenza (H1N1) pneumonia. Because this case occurred during the H1N1 pandemic, the initial diagnostic impression was of H1N1 pneumonia. METHODS Although her clinical and laboratory findings were consistent with the diagnosis of H1N1 pneumonia, e.g., fever, sore throat, dry cough, arthralgias, myalgias, thrombocytopenia, relative lymphopenia, and elevated serum transaminases, some findings suggested an alternate diagnosis, e.g., leukopenia, a highly elevated erythrocyte sedimentation rate, highly elevated serum ferritin levels, elevated antinuclear antibody (ANA) levels, and double-stranded (DS) DNA titers. Her chest x-ray showed an accentuation of basilar lung markings, with a small pleural effusion similar to the chest x-ray findings of early H1N1 pneumonia. Initially, her headaches were thought to be related to central nervous system manifestations of H1N1. RESULTS After laboratory test results demonstrated elevated ANA and anti-DS DNA titers, she was diagnosed with acute SLE pneumonitis. The take-home lesson for clinicians is that other infectious diseases, e.g., human parainfluenza virus or Legionnaires' disease, can mimic H1N1 pneumonia during an influenza pandemic. Excluding asthma, congestive heart failure, exacerbations of acute bronchitis, chronic obstructive pulmonary disorder, and pulmonary interstitial disease, noninfectious mimics of H1N1 are extremely rare. CONCLUSION To the best of our knowledge, this is the first reported case of de novo SLE pneumonitis mimicking H1N1 pneumonia during the swine influenza pandemic.
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Vilà de Muga M, Torre Monmany N, Asensio Carretero S, Travería Casanovas FJ, Martínez Mejías A, Coll Sibina MT, Luaces Cubells C. [Clinical features of influenza A H1N1 2009: a multicentre study]. An Pediatr (Barc) 2011; 75:6-12. [PMID: 21397578 DOI: 10.1016/j.anpedi.2011.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 01/21/2011] [Accepted: 01/24/2011] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe clinical and epidemiological features of influenza A H1N1 2009 diagnosed patients in the Emergency Department of 4 hospitals. MATERIAL AND METHODS Prospective multicentre study conducted from july to december 2009. The patients diagnosed by Real-Time PCR of influenza A H1N1 2009 in the emergency department were included. The test was requested according to the protocols established throughout the epidemic. Epidemiological, clinical, laboratory variables and outcomes were evaluated. RESULTS A total of 456 cases were included, with a median age of 6.5years (PC(25-75) 3-10.6). There were risk factors of complications In 266 patients (59.4%) due to the influenza, mainly: respiratory (47%), cardiovascular (17%), neurological (14%) and immunosuppression (11%). The most frequent symptoms were fever (96%), (88%) cough, (72%) rhinorrhoea, muscle aches or asthenia and breathing difficulties and, less common, gastrointestinal and neurological symptoms. Chest X-ray was performed on 224 cases (49%), with lobar (31%) and interstitial (15%) infiltrates. One hundred and forty patients (31%) were hospitalised and 3.2% required Intensive Care Unit (median stay 4 and 3.5days, respectively). The most frequent complications were pneumonias and bronchospasms. Three patients died (a previously healthy patient with myocarditis and 2 patients with encephalopathy due to respiratory failure). Another case of myocarditis recovered with sequelae. CONCLUSIONS The profile of patient with influenza A 2009 diagnosed in the emergency department was a school child, with risk factors of complications, presenting with respiratory symptoms and fever over a short time, and who can be discharged. It is important to emphasise myocarditis, as well as the usual respiratory complications of influenza virus.
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Affiliation(s)
- M Vilà de Muga
- Servicio de Urgencias, Servicio de Pediatría, Hospital Universitari Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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Cunha BA, Corbett M, Mickail N. Human parainfluenza virus type 3 (HPIV 3) viral community-acquired pneumonia (CAP) mimicking swine influenza (H1N1) during the swine flu pandemic. Heart Lung 2011; 40:76-80. [DOI: 10.1016/j.hrtlng.2010.05.060] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Accepted: 05/28/2010] [Indexed: 11/26/2022]
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Cunha BA, Syed U, Strollo S. Non-specific laboratory test indicators of severity in hospitalized adults with swine influenza (H1N1) pneumonia. Eur J Clin Microbiol Infect Dis 2010; 29:1583-8. [DOI: 10.1007/s10096-010-1069-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 09/19/2010] [Indexed: 11/28/2022]
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Rapid clinical diagnosis of swine influenza (H1N1) using the Swine influenza diagnostic triad. Heart Lung 2010; 39:461. [DOI: 10.1016/j.hrtlng.2010.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Cunha BA, Klein NC, Strollo S, Syed U, Mickail N, Laguerre M. Legionnaires' disease mimicking swine influenza (H1N1) pneumonia during the "herald wave" of the pandemic. Heart Lung 2010; 39:242-8. [PMID: 20457347 PMCID: PMC7112534 DOI: 10.1016/j.hrtlng.2009.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 10/21/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND New York area hospitals were hit hard by the swine influenza (H1N1) pandemic in spring and summer 2009. During a pandemic, the initial cases may be difficult to recognize, but subsequent clinical diagnoses were relatively straightforward, given the high volume of cases and their typical clinical presentation. Swine influenza pneumonia presents as an influenza-like illness (ILI) with dry cough, fever >102 degrees F and myalgias. A variety of other viral pneumonias, eg, cytomegalovirus, human parainfluenza virus 3 (HPIV 3), and adenovirus, as well as bacterial community-acquired pneumonias (CAPs) that may present with some of the clinical and laboratory features of H1N1 pneumonia. Most adults admitted to hospitals with ILIs during the pandemic had, in fact, definite or probable H1N1 pneumonia. The Infectious Disease Division at Winthrop-University Hospital developed a diagnostic weighted point score to identify probable H1N1 cases in hospitalized adults with rapid negative influenza diagnostic tests (RIDTs). METHODS We present a case of an elderly male who presented with an ILI and negative RIDTs during the H1N1 pandemic. He was admitted with a diagnosis of possible H1N1, and placed on influenza precautions and oseltamivir. Although the patient had features consistent with H1N1 pneumonia, Legionnaires' disease was included in the differential diagnosis because of his elevated serum ferritin levels. A Legionella urinary antigen test was positive for Legionella pneumophila (serogroups 01-06). RESULTS The peak seasonal incidence of sporadic Legionnaires' disease occurs in the summer and fall. Even in the midst of a pandemic, clinicians should be on the alert for other infectious diseases that may mimic H1N1 pneumonia. In our experience, the best way to differentiate H1N1 from ILIs or other bacterial CAPs is through the Winthrop-University Hospital Infectious Disease Division's diagnostic weighted point score system for H1N1 pneumonia or its rapid simplified version, ie, the diagnostic swine influenza triad. Legionnaires' disease is the atypical CAP pathogen most likely to mimic H1N1 pneumonia. CONCLUSIONS Based on this and other nine cases at our institution during the "herald wave" of pandemic, we conclude that Legionnaires' disease may mimic swine influenza (H1N1) pneumonia.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA
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Abstract
Influenza is a viral zoonosis of birds and mammals that has probably existed since antiquity. Attack rates of influenza are relatively high but mortality is relatively low. Influenza mortality is highest in the very young, the very old, and the immunosuppressed. Influenza has the potential for rapid spread and may involve large populations. This article examines the swine influenza (H1N1) strain of recent origin, and compares the microbiology, epidemiology, clinical presentation, differential, clinical, and laboratory diagnosis, therapy, complications, and prognosis with previous recorded outbreaks of avian and human seasonal influenza pneumonias.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, 259 First Street, Mineola, Long Island, NY 11501, USA
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Cunha BA, Syed U, Mickail N, Strollo S. Rapid clinical diagnosis in fatal swine influenza (H1N1) pneumonia in an adult with negative rapid influenza diagnostic tests (RIDTs): diagnostic swine influenza triad. Heart Lung 2010; 39:78-86. [PMID: 20109989 PMCID: PMC7112666 DOI: 10.1016/j.hrtlng.2009.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 10/03/2009] [Indexed: 11/01/2022]
Abstract
BACKGROUND The "herald wave" of the H1N1 pandemic spread from Mexico to the United States in spring 2009. Initially, the epicenter of H1N1 in the United States was in the New York area. Our hospital, like others, was inundated with large numbers of patients who presented at the Emergency Department (ED) with influenza-like illnesses (ILIs) for swine influenza testing and evaluation. METHODS The Winthrop-University Hospital ED used rapid influenza (QuickVue A/B) tests to screen for H1N1 infection. Patients who were rapid influenza A test-positive were also reverse transcription-polymerase chain reaction (RT-PCR) positive for H1N1. In our ED, 30% of patients with ILIs and possible H1N1 pneumonia had negative rapid influenza A screening tests. Because H1N1 RT-PCR testing was restricted, there was no laboratory test to confirm or rule out H1N1. Other rapid influenza diagnostic tests (RIDTs), e.g., the respiratory fluorescent antibody (FA) viral panel test, were used to identify H1N1 patients with negative RIDTs. RESULTS Unfortunately, there was not a good correlation between RIDT results and RT-PCR results. There was a critical need to develop a clinical syndromic approach for diagnosing hospitalized adults with probable H1N1 pneumonia with negative RIDTs. Early in the pandemic, the Winthrop-University Hospital Infectious Disease Division developed a diagnostic weighted point score system to diagnose H1N1 pneumonia clinically in RIDT-negative adults. The point score system worked well, but was time-consuming. As the "herald wave" of the pandemic progressed, our ED staff needed a rapid, simplified method to diagnose probable H1N1 pneumonia in hospitalized adults with negative RIDTs. A rapid and simplified diagnosis was based on the diagnostic weighted point score system, which we simplified into a triad of key, nonspecific laboratory indicators. In adults hospitalized with an ILI, a fever >102 degrees F with severe myalgias, and a chest x-ray without focal segmental/lobar infiltrates, the presence of three indicators, i.e., otherwise unexplained relative lymphopenia, elevated serum transaminases, and an elevated creatinine phosphokinase, constituted the diagnostic swine influenza triad. The Infectious Disease Division's diagnostic swine flu triad was used effectively as the pandemic progressed, and was not only useful in correctly diagnosing probable H1N1 pneumonia in hospitalized adults with negative RIDTs, but was also in ruling out mimics of swine influenza, e.g., exacerbations of chronic bronchitis, asthma, or congestive heart failure, as well as bacterial community-acquired pneumonias (CAPs), e.g., legionnaire's disease. CONCLUSION Clinicians can use the Winthrop-University Hospital Infectious Disease Division's Diagnostic swine influenza triad to make a rapid clinical diagnosis of probable H1N1 pneumonia in hospitalized adult patients with negative RIDTs.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA
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Cunha BA, Syed U, Stroll S, Mickail N, Laguerre M. Winthrop-University Hospital Infectious Disease Division's swine influenza (H1N1) pneumonia diagnostic weighted point score system for hospitalized adults with influenza-like illnesses (ILIs) and negative rapid influenza diagnostic tests (RIDTs). Heart Lung 2009; 38:534-8. [PMID: 19944879 PMCID: PMC7119053 DOI: 10.1016/j.hrtlng.2009.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 09/09/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND In spring 2009, a novel strain of influenza A originating in Veracruz, Mexico, quickly spread to the United States and throughout the world. This influenza A virus was the product of gene reassortment of 4 different genetic elements: human influenza, swine influenza, avian influenza, and Eurasian swine influenza. In the United States, New York was the epicenter of the swine influenza (H1N1) pandemic. Hospital emergency departments (EDs) were inundated with patients with influenza-like illnesses (ILIs) requesting screening for H1N1. Our ED screening, as well as many others, used a rapid screening test for influenza A (QuickVue A/B) because H1N1 was a variant of influenza A. The definitive laboratory test i.e., RT-PCR for H1N1 was developed by the Centers for Disease Control (Atlanta, GA) and subsequently distributed to health departments. Because of the extraordinary volume of test requests, health authorities restricted reverse transcription polymerase chain reaction (RT-PCR) testing. Hence most EDs, including our own, were dependent on rapid influenza diagnostic tests (RIDTs) for swine influenza. A positive rapid influenza A test was usually predictive of RT-PCR H1N1 positivity, but the rapid influenza A screening test (QuickVue A/B) was associated with 30% false negatives. The inability to rely on RIDTs for H1N1 diagnosis resulted in underdiagnosing H1N1. Confronted with adults admitted with ILIs, negative RIDTs, and restricted RT-PCR testing, there was a critical need to develop clinical criteria to diagnose probable swine influenza H1N1 pneumonia. METHODS During the pandemic, the Infectious Disease Division at Winthrop-University Hospital developed clinical criteria for adult admitted patients with ILIs and negative RIDTs. Similar to the one developed for the clinical diagnosis of legionnaire's disease. The Winthrop-University Hospital Infectious Disease Division's diagnostic weighted point score system for swine influenza H1N1 pneumonia is based on key clinical and laboratory features. RESULTS During the "herald" wave of the swine influenza H1N1 pandemic, the diagnostic weighted point score system accurately identified probable swine influenza H1N1 pneumonia and accurately differentiated swine influenza H1N1 pneumonia from ILIs and other viral and bacterial community-acquired pneumonias. CONCLUSION In hospitalized adults with ILIs and negative RIDTs, the diagnostic weighted diagnostic point score system, may be used to make a presumptive clinical diagnosis of swine influenza H1N1 pneumonia.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA
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