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CATIE-News: Bite-sized HIV/AIDS news bulletinsFatal case of pneumonia with swine flu and HIVA pandemic influenza virus called H1N1 (also known as Swine flu) emerged in April 2009 and quickly spread around the world. For comprehensive information on H1N1 prevention and treatment, see the CATIE News bulletin H1N1 and HIV: tips to keep you safe and healthy, published October 30, 2009, at this link: www.catie.ca/catienews.nsf/CATIE-NEWS In 2009, there were many reports from middle- and high-income countries about H1N1 infection and associated complications and, in some cases, deaths. Globally, millions of people have likely developed H1N1 infection but there were no reports of severe H1N1-related complications in HIV-positive people until a report was published in the January 2010 issue of the journal Emerging Infectious Diseases. In that report, doctors in Long Island, New York, provided details of a fatal case of pneumonia related to H1N1 infection. Case detailsA 39-year-old HIV-positive woman with type-1 diabetes sought care at Winthrop-University Hospital (Mineola, NY) because of shortness of breath and other symptoms. She had been caring for a child who had an influenza-like illness. The woman had been diagnosed with AIDS seven years earlier. Before entering the hospital she had been prescribed and was supposed to be taking the following drugs:
However, the woman’s CD4+ count was low, about 166 cells, and the hospital doctors noted that she had not taken her medications as directed. They did not provide reasons for her non-adherence. At the hospital the woman had the following signs and symptoms:
Lab tests for respiratory viruses, including rapid influenza test and viral culture, did not return a positive result. An X-ray scan of her chest revealed some inflammation. Because of several factors—the negative rapid influenza test result, her low CD4+ count and history of bacterial chest infections—doctors presumed that she was suffering from a recurrence of a bacterial infection or an AIDS-related pneumonia. They prescribed a broad range of antibiotics and the drug atovaquone (Mepron), which can be used to treat an AIDS-related pneumonia called PCP. Intensive careOver the next two days, despite the use of antibiotics, the woman’s condition grew worse as her blood pressure fell and breathing became more difficult. She was transferred to the hospital’s intensive care unit (ICU). There, her breathing was assisted and fluid building up in her lungs was removed. On the third day of hospitalization, doctors changed her antibiotics and also began giving her oseltamivir (Tamiflu), 150 mg twice daily, to treat a presumed influenza infection. Another chest X-ray scan revealed inflammation in her right lung. Doctors took a sample of fluid from that lung and had it analysed for bacteria, fungi and viruses, but all tests returned with negative results. On her fifth day in the hospital, although rapid testing for influenza viruses, fluorescent influenza antibody test and viral culture were again all negative, PCR tests detected H1N1 from a nasal swab. Despite continued treatment with oseltamivir, the woman died on her 11th day in the hospital. A cautionary taleAfter reviewing the doctors’ report, in hindsight, some readers may be tempted to say that perhaps oseltamivir should have been prescribed on admission to the hospital. Bear in mind that the woman was infected during the first wave of pandemic H1N1. At that time doctors would have had little experience diagnosing and treating this infection. The hospital doctors did initially consider the possibility that the woman had H1N1 because her child had an influenza-like illness. However, the doctors pointed out that because initial tests for influenza were repeatedly negative they did not initially make a diagnosis of H1N1 infection. Instead they were concerned that she might have had a serious AIDS-related chest infection. Certainly, the woman had a history of such infections. As a result, they did not initially prescribe oseltamivir. The hospital physicians finished their report by making these two points:
The woman sought care early in June 2009. In August, the U.S. Centers for Disease Control and Prevention (CDC) and published reports from different research teams alerted health care workers that rapid tests for influenza and H1N1 are not as reliable as other tests such as PCR. The report from the Long Island doctors underscores the importance of early care and treatment for H1N1. Also, HIV-positive people with weakened immunity (less than 200 CD4+ cells) and additional health conditions may be at heightened risk for complications arising from H1N1 infection. A vaccine against H1N1 was not available before the HIV-positive woman from Long Island became ill. Reports from Canada and the United States suggest that pre-existing health conditions in HIV-negative people—including asthma, cardiovascular disease, diabetes, tobacco addiction, lung disease and obesity—were relatively common in people who developed H1N1 and who needed to be hospitalized. However, one recent report from Mexico suggests that severe pneumonia can occur even in healthy young adults who become infected with H1N1. In light of the Long Island doctors’ report, and given that H1N1 vaccines are now widely available in high-income countries, HIV-positive people in Canada and other high-income countries who have not already done so should consider getting vaccinated against H1N1. —Sean R. Hosein REFERENCES:
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Created on: 01/11/2010 |
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Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner who is knowledgeable about HIV-related illness and the treatments in question. MORE | |