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Clinical course of H5N1 avian influenza in patients at the Persahabatan Hospital, Jakarta, Indonesia, 2005-2008.
Priyanti Z Soepandi1, Erlina Burhan1,*, Hadiarto Mangunnegoro1, Arifin Nawas1, Tjandra Yoga Aditama1, Lia Partakusuma1, Fathiyah Isbaniah1, Suhud Malik2, Rachel Benamore3, J Kevin Baird4,5, Walter RJ Taylor5,6 and the H5N1 clinical team¶
Abstract
Background: Limited understanding of the presentation and course of influenza A/H5N1 infection in humans hinders evidence-based management.
Methods: Review of case records of patients with real time, PCR confirmed H5N1 influenza admitted to the Persahabatan Hospital (RSP), Jakarta, Indonesia.
Results: 22 previously well patients, age 3 to 47 years (median 24.5), were identified. All attended a clinic or hospital after a median of 2 days of illness (range 0-7). Times to first dose of oseltamivir (3 died before receiving oseltamivir) were 2 to 12 days (median 7), administered mostly (n=15) at RSP. 19 patients required mechanical ventilation. Deaths numbered 18 (case fatality=82%
occurring within hours to 6 days of RSP admission, corresponding to 6 to 16 days of illness.
Admission hyperglycemia (≥ 140 mg/dL), unrelated to steroids or known underlying diabetes mellitus, and raised d-dimers (0.81 – 5.2 mg/L, ULN < 0.5 mg/L) were present in 14/21 (67%) and 20/21 (95%) patients, respectively. Fibrinogen concentrations were mostly low/normal 129.9-517.9 mg/dL (median 241.1, normal 200-400 mg/dL) whilst CRP (9/11) and ferritin (6/8) were raised. Risk factors for death (univariate analysis) included: (i) raised d-dimers, (ii) hyperglycemia, (iii) raised urea, (iv) more extensive chest X ray shadowing, and (v) lower admission oxygen saturation.
Conclusions: Early diagnosis and effective treatment of human H5N1 infection remains challenging. Most patients were referred late with advanced disease. Oseltamivir had limited clinical impact. Raised d-dimers, consistent with fibrinolysis, and hyperglycemia warrant more research to determine their underlying mechanisms and optimal treatment.
Priyanti Z Soepandi1, Erlina Burhan1,*, Hadiarto Mangunnegoro1, Arifin Nawas1, Tjandra Yoga Aditama1, Lia Partakusuma1, Fathiyah Isbaniah1, Suhud Malik2, Rachel Benamore3, J Kevin Baird4,5, Walter RJ Taylor5,6 and the H5N1 clinical team¶
Abstract
Background: Limited understanding of the presentation and course of influenza A/H5N1 infection in humans hinders evidence-based management.
Methods: Review of case records of patients with real time, PCR confirmed H5N1 influenza admitted to the Persahabatan Hospital (RSP), Jakarta, Indonesia.
Results: 22 previously well patients, age 3 to 47 years (median 24.5), were identified. All attended a clinic or hospital after a median of 2 days of illness (range 0-7). Times to first dose of oseltamivir (3 died before receiving oseltamivir) were 2 to 12 days (median 7), administered mostly (n=15) at RSP. 19 patients required mechanical ventilation. Deaths numbered 18 (case fatality=82%
occurring within hours to 6 days of RSP admission, corresponding to 6 to 16 days of illness.Admission hyperglycemia (≥ 140 mg/dL), unrelated to steroids or known underlying diabetes mellitus, and raised d-dimers (0.81 – 5.2 mg/L, ULN < 0.5 mg/L) were present in 14/21 (67%) and 20/21 (95%) patients, respectively. Fibrinogen concentrations were mostly low/normal 129.9-517.9 mg/dL (median 241.1, normal 200-400 mg/dL) whilst CRP (9/11) and ferritin (6/8) were raised. Risk factors for death (univariate analysis) included: (i) raised d-dimers, (ii) hyperglycemia, (iii) raised urea, (iv) more extensive chest X ray shadowing, and (v) lower admission oxygen saturation.
Conclusions: Early diagnosis and effective treatment of human H5N1 infection remains challenging. Most patients were referred late with advanced disease. Oseltamivir had limited clinical impact. Raised d-dimers, consistent with fibrinolysis, and hyperglycemia warrant more research to determine their underlying mechanisms and optimal treatment.
