CMJ: Varied Clinical Presentations Of H7N9

 

# 7997

 

 

While we’ve only seen a limited number H7N9 infections in China, as studies are published we are learning more about the different ways this virus manifests in patients, with some  experiencing relatively mild illness, while others progress to ARDS and even death.

 

Last month in PLoS One: Epidemiological & Clinical Description Of 6 H7N9 Cases – Shanghai we looked at the course of illness among a half dozen patients treated at Fifth People’s Hospital of Shanghai, as well as a study on Hematological & Biochemical Abnormalities In H7N9 Patients in the Journal of Medical Virology.

 

Today, a pair of reports from the Chinese Medical Journal (CMJ) that discuss four unusual H7N9 presentations (h/t @Ironorehopper), including both cardiovascular and neurological complications.

 

First stop, a brief letter describing a non-typical presentation in an 87 year-old man, who initially (April 4th) complained of loss of appetite and strength but no fever, cough, or expectoration.  Chest x-rays on the 6th indicated some lung inflammation, but due to his symptoms a bacterial, not a viral cause, was suspected.  He admitted to the hospital and was placed on antibiotics (cefuroxime).

 

Five days into his illness, he developed dyspnea (shortness of breath) and an elevated temperature, and on April 10th deteriorated further. Influenza was finally suspected, and he was started on oseltamivir and levofloxacin, and a decision to test for H7N9 was made. 

 

Despite ICU treatment, and a transfer to specialized hospital, the patient died on April 21st.

 

The authors write:

This case history serves to remind us that we need timely use of antiviral treatment, even for the patients whose clinical manifestations are not typical but whose lung inflammation may be developing rapidly. Careful clinical observation needs to be carried out so that appropriate treatment can begin as early as possible and progression culminating in death is minimized

 

The entire letter may be read at:

 

Chinese Medical Journal 2013;126(22):4399-4399

A case with non-typical clinical course of H7N9 avian influenza

ZHENG Yu-fang, CAO Ye, LU Yun-fei, XI Xiu-hong, QIAN Zhi-ping, Lowrie Douglas, LIU Xi-nian, WANG Yan-bin, ZHANG Qi, LU Shui-hua and LU Hong-zhou

 

 

A second, more detailed report also appears in the Chinese Medical Journal, that looks at three H7N9 cases, and the variability in their clinical presentation – including neurological and cardiovascular manifestations.

 

The authors write:

In this report, the initial clinical manifestations of three confirmed cases are summarized. Two of the patients were in critical condition. In addition, two of the patients experienced changes in mental status, one of which was believed to be the first published case with Brugada syndrome associated with H7N9 infection in China. We suggest that this H7N9 virus causes various signs and symptoms in the early stages of infection.

 

We’ve seen reports of neurological complications with influenza in the past (see Neurologic Manifestations of Pandemic (H1N1) 2009 Virus Infection), but the bulk of these cases have involved children or adolescents. And we’ve also seen studies that suggest that influenza can induce cardiogenic changes as well (see  Another Study Links Heart Attacks & Influenza). 

 

So while these H7N9 cases are the first to be documented in China with these complications, their existence is not without precedence.

 

Follow the link below to read the complete case histories of all three patients (age range 39 to 69), two of whom survived.  For those unfamiliar with Brugada syndrome, is a relatively recently (1992) recognized condition that is characterized by an abnormal EKG that signifies an increased risk of sudden cardiac arrest.

 

Chinese Medical Journal 2013;126(21):4194-4196

Clinical variability in onset of influenza A (H7N9) infection

WANG Shu-ying, REN Shu-hua, HUANG Mei-xian, YU Dao-jun, SHEN Qiang, ZHAO Hong-feng, LÜ Qiao-hong and QIAN Shen-xian

(EXCERPT)

Based on these case reports, patients with H7N9 influenza virus infection from symptom onset to laboratory confirmation showed variable findings in clinical manifestation. Patients with H7N9 infection present variable symptoms: fever, cough, phlegm production, hemoptysis, chest tightness, diarrhea, and disturbance of consciousness. Detection of the nucleic acids of H7N9 virus in the throat swab specimens may show negative results in the early stage. Clinicians should remain vigilant to the possibility of H7N9 infection associated with neurological and cardiovascular complications, because the novel virus may unmask some underlying diseases. Documentation of

 

 

Four cases out of a pool of just over 130 doesn’t really tell us a lot about the incidence of these atypical findings, but it does serve to remind us that a severe influenza infection can impact our physiology in many ways, and can exacerbate many previously existent (even if not previously diagnosed) conditions.

ER Truisms, Medical Acronyms & The Unfortunate Return of Polyidiotitis

 

 

 

# 7489

 

And now for something completely different . . .

 

Although it isn’t always apparent to the general public - doctors, nurses, and other healthcare providers often have a wicked – if not always completely appropriate, sense of humor. 

 

It’s a built-in defense system, that allows them to deal with the never-ending parade of emergencies (or PITAs) they must deal with each day. 

Back in 2009, I wrote about some of the medical acronyms that were used when I was a young medic (long ago, in a galaxy far, far away . . .) in Kick In The TEETH.

 

• FUO, for instance,  was Fever of Undetermined Origin.

Pretty innocuous, and unlikely to come back and bite you in a court of law. I suspect it is still used most places.

 

Others are far less PC (but a lot funnier!), and would no doubt prove `problematic’ in any legal review of a patient’s chart.

 

Some of the more famous ones include:

• GOMER -  Get Out of My Emergency Room (reserved for nuisance patients, often `frequent flyers’)
• CTD -  Circling The Drain (Patients near death, not expected to survive)
• DFO - Done Fell Out (anything from fainting to cardiac arrest)
• ETOH- Abbreviation for Ethanol (but can also stand for Extremely Trashed Or Hammered – i.e. Drunk)
• FDGB – Fall Down, Go Boom (same as DFO, but usually elderly)
• FLK-  Funny looking kid 
• Positive `O’ Sign – Comatose, mouth wide open
• Positive `Q’ Sign – Comatose , mouth wide open, tongue protruding.
• PITA – Pain In The Ass

And perhaps the most famous of all; GOK – God Only Knows (perplexing symptoms)

 

I rehash these whimsical acronyms today because the Annals of Emergency Medicine has published in their July, 2013 edition an inspired bit of medical lunacy that anyone with an emergency medical background will appreciate.

 

(For everyone else, I do apologize, as much of this will probably make no sense whatsoever . . .)

 

By all means, follow the link to read:

 

 

 

Annals of Emergency Medicine
Volume 62, Issue 1 , Page 95, July 2013

An Absurdly Random, and Completely Blind, Review and Prospective Validation of Mathematical Truisms in Emergency Medicine and Critical Care

Torrey Goodman, MD

Study Objective

We thought that in the darkest part of night shifts, when the diurnal variation of our internal clocks is defunct and all organized neuronal electrical activity in the cerebrum has ceased, that mathematical truisms might be a valid tool in the assessment and treatment of the acutely ill, injured, or merely crazy patients in the emergency department (ED). Therefore, in support of evidence-based medicine, we sought to define and subsequently validate any mathematical information that may be clinically useful at 3 am.

(Continue . . . )

Dr. Goodman, I salute you.  You’ve penned a classic.

 

Very long-time readers of this blog may recall that back in early 2006 I wrote my own `mock’ paper on Polyidiotitis ( a condition which quite sadly, still remains unrecognized by the medical community).

Polyidiotitis : Diagnosis and Treatment.

 
It has been said that the first casualty of any war is the truth. Undoubtedly true. During an emergency, the first casualty is usually common sense. During a large-scale event, such as a Pandemic, Earthquake or Hurricane, Polyidiotitis, an insidious and serious disease, runs rampant.

 

No one is immune, and the symptoms may not always be obvious early on. Even professional responders have been known contract this oft times embarrassing and sometimes deadly disease. Etiology of this disorder is poorly understood, but clustering of cases is common, suggesting a human-to-human vector.

 

Person’s afflicted with this disease often exhibit the following symptoms. Rapid pulse, increased blood pressure, rapid, oft times shallow breathing, and bizarre psychiatric manifestations that include, but are not limited to, a feeling of invulnerability or immortality. This may be a dissociative disorder, as victims of Polyidiotitis seem to lose any vestige of situational awareness. They develop a narrow focus, a tunnel vision of sorts, that diminishes their ability to make rational decisions.

 

Clearly there is a disconnect in the patient between reality their perception thereof. Victims of this disease may argue, quite convincingly, that there is absolutely nothing wrong. When confronted, they may even become combative.

 

Those in close contact with these subjects must take care not to become afflicted themselves (see Lemming’s Disease).

 

A paradoxical response is sometimes seen in Polyidiotitis, characterized by denial and decent into a semi-fugue state. These victims, while not exhibiting the classic symptoms of Polyidiotitis, are just as profoundly affected. They often fail to take action, or prepare, in the face of an advancing threat. Indeed, their dissociation may be so complete that they simply are unable to accept that any threat exists.

 

For reasons not yet known, this paradoxical response has been found to be most prevalent in politicians, business leaders, and people in authority.

(Continue . . . )

 

They say that if you look back at something you wrote more than 5 years ago and aren’t at least a little bit embarrassed, then you haven’t progressed as a writer.

The good news is, after re-reading this piece, I find myself slightly mortified. But not so much that I wasn’t willing to dredge it up again.

 

I guess that’s progress.