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Editor, Senior Moderator
At death's door with H1N1 for three weeks
Bruce Bisping, Star Tribune
By JOSEPHINE MARCOTTY, Star Tribune
Last update: December 6, 2009
Kim Lange's son was still coherent when the doctor said it was time to put him on a ventilator. He was as stoic as he could be -- a 23-year-old who had never been sick. But the look of terror in his eyes as he looked up from the hospital bed tore her heart.
"He said, 'Worst- case scenario, huh, Mom?' '' Lange recalled. "And I fell apart.''
Her son, Brad, just had the flu. The same H1N1 virus that has infected an estimated 22 million people in the United States -- and left most of them largely unscathed.
But in a small fraction of children and young adults the virus is unexpectedly deadly. For unknown reasons some perfectly healthy patients, like Brad Lange, end up in the intensive care unit, drowning in their own fluids.
It's a mystery that health officials badly want to solve, because H1N1 will most likely be back, maybe sooner than later.
As the New England Journal of Medicine put it recently: "No one should be complacent about an unpredictable virus capable of killing children and young adults in their prime."
Kim Lange certainly isn't.
Not anymore.
"Brad was always so proud that he never got sick," she said. "That's why this is so unusual that it would happen to him of all people." Brad Lange, of Hugo, started feeling lousy on a Saturday in mid-October. He was at a furniture store with his fiance, and he remembers looking longingly at the couches, keeping his eye out for the one he could fall into if he passed out.
On Monday he went to the doctor, who told him he had pneumonia and sent him home with pills. On Tuesday, when his temperature hit 104 degrees, his mom took him to the emergency room, where he got intravenous fluids and more pills. On Wednesday he went back to the doctor, who called an ambulance to take him from the clinic in Forest Lake to United Hospital in St. Paul. An ambulance? Kim Lange was shocked.
"Pneumonia. That was all. That's what I had," Brad Lange recalled. "I didn't know how serious pneumonia can get."
On Friday, after two nights in the hospital, he could hardly breathe. A lung specialist at United told him his lungs were worsening. On the X-ray they were solid white, filled with fluid. He was going to the intensive care unit, she said.
"He asked the doctor: 'What's the worst-case scenario, here?' " Kim Lange said. "She said, 'The worst case scenario is we put you on a ventilator so your lungs can heal.' "
The next morning they put him on the ventilator. Only that wasn't the worst.
All week long Kim Lange had noticed a strange contraption in the room next to her son's. It was an enormous, tubular bed covered with padding.
In it was a patient, who, like Brad, couldn't breathe. All that was visible to her were his feet as every half hour or so the bed rotated half a turn.
"For two days we were walking past this room and watching this thing. All I kept thinking was, I hope that doesn't happen," she said.
On Saturday night, they brought in the bed.
The problem was the fluid in Brad's lungs. He had a full-blown case of adult respiratory distress syndrome, or ARDS. It's the result of an immune system run amok, expert say.
ARDS often starts with an infection, not necessarily influenza. The infection triggers the body's immune system to attack the foreign invaders.
But in some people with H1N1 the immune system overreacts. It sends out millions of cells called cytokines, which normally coordinate the body's defense against invaders. Only in ARDS, the immune system creates what experts call a cytokine storm -- a massive inflammation that floods the lungs with proteins, blood and fluids.
There is no way to stop it, said Dr. Samy El Halawani, one of Brad's doctors.
"You wait. You wait for the lungs to heal themselves," he said. The bed, called a RotoProne, is used in extreme cases. The rotation of the bed moves the fluid around in the lungs, increasing oxygen in the body and allowing the lung tissue to heal.
Brad Lange was in the bed for nine days.
His doctors weren't sure what had caused the pneumonia. He was tested for every kind of pathogen they could think of, including H1N1, but the results all came back negative or inconclusive.
In the middle of Brad's second week in the hospital, Dr. Jason Wirtz asked the Langes for permission to give their son an experimental drug called Peramivir. Like Tamiflu, it's designed to suppress the flu virus in the body, but it can be given intravenously to patients who are unconscious.
"We felt it was a last resort," said Kim Lange. "It was presented to us like that."
She was right, said Wirtz. "We were trying to do everything possible to save his life," he said. "It was touch and go."
The next day Brad's breathing started to improve. For the first time in nearly two weeks, Kim Lange felt hopeful. For the next five days they watched the numbers on his ventilator tick down and down -- a sign that his lungs were healing.
On Monday, Nov. 2, nurses took him off the ventilator and started weaning him from the sedation. On Tuesday morning he opened his eyes, and the whole family started crying.
Finally, Eric could talk
"He was saying, 'I love you guys.' His mouth was so dry and his throat hurt," Kim Lange said. "But he got that out pretty good."
Weeks later Wirtz got the final test results on Brad Lange - he did have H1N1. It's impossible to know for sure whether the Peramivir made a difference at that point in his illness. But suppressing the virus, in theory, would stop the cascading immune response that flooded his lungs, Wirtz said.
It's too soon to know how many of the nearly 100,000 people who have been hospitalized with H1N1 since it emerged in this country in April had ARDs. Many serious illnesses and deaths are related to underlying conditions such as asthma or diabetes, or bacterial infections that occur along with H1N1.
But there are enough such cases to worry health officials.
For example, a preliminary study of about 650 H1N1 patients hospitalized in the Twin Cities showed that 5.4 percent had a diagnosis of ARDS, said Dr. Ruth Lynfield, state epidemiologist. Similar reports have come from New Zealand, Canada and Europe.
Why does it happen to some people but not others?
No one knows for sure, but one prevailing theory is that it's genetic, said Dr. Greg Poland, an infectious-disease expert at the Mayo Clinic.
Some people inherit an immune system that does not protect them from certain strains of influenza or other infections. The reverse is also true.
For example, some people can be infected with HIV, the virus that causes AIDs, and never get sick, he said.
"It's the immune response genes that they carry -- or not," he said.
At this point, Poland says, it seems not that many people are susceptible to such an extreme response to H1N1. But flu viruses are notorious for their ability to mutate, and they fear that H1N1 could morph into something lethal to more people.
Brad Lange was released from the hospital three weeks to the day after he was admitted. He left 20 pounds lighter and with a new respect for influenza. He remembers almost nothing of his stay - just the nightmares he had while sedated.
"I dreamt that I couldn't move. That things were happening to me and I couldn't do anything about it," he said.
http://www.startribune.com/lifestyle/health/virus/78612267.html?page=1&c=y
Bruce Bisping, Star Tribune
By JOSEPHINE MARCOTTY, Star Tribune
Last update: December 6, 2009
Kim Lange's son was still coherent when the doctor said it was time to put him on a ventilator. He was as stoic as he could be -- a 23-year-old who had never been sick. But the look of terror in his eyes as he looked up from the hospital bed tore her heart.
"He said, 'Worst- case scenario, huh, Mom?' '' Lange recalled. "And I fell apart.''
Her son, Brad, just had the flu. The same H1N1 virus that has infected an estimated 22 million people in the United States -- and left most of them largely unscathed.
But in a small fraction of children and young adults the virus is unexpectedly deadly. For unknown reasons some perfectly healthy patients, like Brad Lange, end up in the intensive care unit, drowning in their own fluids.
It's a mystery that health officials badly want to solve, because H1N1 will most likely be back, maybe sooner than later.
As the New England Journal of Medicine put it recently: "No one should be complacent about an unpredictable virus capable of killing children and young adults in their prime."
Kim Lange certainly isn't.
Not anymore.
"Brad was always so proud that he never got sick," she said. "That's why this is so unusual that it would happen to him of all people." Brad Lange, of Hugo, started feeling lousy on a Saturday in mid-October. He was at a furniture store with his fiance, and he remembers looking longingly at the couches, keeping his eye out for the one he could fall into if he passed out.
On Monday he went to the doctor, who told him he had pneumonia and sent him home with pills. On Tuesday, when his temperature hit 104 degrees, his mom took him to the emergency room, where he got intravenous fluids and more pills. On Wednesday he went back to the doctor, who called an ambulance to take him from the clinic in Forest Lake to United Hospital in St. Paul. An ambulance? Kim Lange was shocked.
"Pneumonia. That was all. That's what I had," Brad Lange recalled. "I didn't know how serious pneumonia can get."
On Friday, after two nights in the hospital, he could hardly breathe. A lung specialist at United told him his lungs were worsening. On the X-ray they were solid white, filled with fluid. He was going to the intensive care unit, she said.
"He asked the doctor: 'What's the worst-case scenario, here?' " Kim Lange said. "She said, 'The worst case scenario is we put you on a ventilator so your lungs can heal.' "
The next morning they put him on the ventilator. Only that wasn't the worst.
All week long Kim Lange had noticed a strange contraption in the room next to her son's. It was an enormous, tubular bed covered with padding.
In it was a patient, who, like Brad, couldn't breathe. All that was visible to her were his feet as every half hour or so the bed rotated half a turn.
"For two days we were walking past this room and watching this thing. All I kept thinking was, I hope that doesn't happen," she said.
On Saturday night, they brought in the bed.
The problem was the fluid in Brad's lungs. He had a full-blown case of adult respiratory distress syndrome, or ARDS. It's the result of an immune system run amok, expert say.
ARDS often starts with an infection, not necessarily influenza. The infection triggers the body's immune system to attack the foreign invaders.
But in some people with H1N1 the immune system overreacts. It sends out millions of cells called cytokines, which normally coordinate the body's defense against invaders. Only in ARDS, the immune system creates what experts call a cytokine storm -- a massive inflammation that floods the lungs with proteins, blood and fluids.
There is no way to stop it, said Dr. Samy El Halawani, one of Brad's doctors.
"You wait. You wait for the lungs to heal themselves," he said. The bed, called a RotoProne, is used in extreme cases. The rotation of the bed moves the fluid around in the lungs, increasing oxygen in the body and allowing the lung tissue to heal.
Brad Lange was in the bed for nine days.
His doctors weren't sure what had caused the pneumonia. He was tested for every kind of pathogen they could think of, including H1N1, but the results all came back negative or inconclusive.
In the middle of Brad's second week in the hospital, Dr. Jason Wirtz asked the Langes for permission to give their son an experimental drug called Peramivir. Like Tamiflu, it's designed to suppress the flu virus in the body, but it can be given intravenously to patients who are unconscious.
"We felt it was a last resort," said Kim Lange. "It was presented to us like that."
She was right, said Wirtz. "We were trying to do everything possible to save his life," he said. "It was touch and go."
The next day Brad's breathing started to improve. For the first time in nearly two weeks, Kim Lange felt hopeful. For the next five days they watched the numbers on his ventilator tick down and down -- a sign that his lungs were healing.
On Monday, Nov. 2, nurses took him off the ventilator and started weaning him from the sedation. On Tuesday morning he opened his eyes, and the whole family started crying.
Finally, Eric could talk
"He was saying, 'I love you guys.' His mouth was so dry and his throat hurt," Kim Lange said. "But he got that out pretty good."
Weeks later Wirtz got the final test results on Brad Lange - he did have H1N1. It's impossible to know for sure whether the Peramivir made a difference at that point in his illness. But suppressing the virus, in theory, would stop the cascading immune response that flooded his lungs, Wirtz said.
It's too soon to know how many of the nearly 100,000 people who have been hospitalized with H1N1 since it emerged in this country in April had ARDs. Many serious illnesses and deaths are related to underlying conditions such as asthma or diabetes, or bacterial infections that occur along with H1N1.
But there are enough such cases to worry health officials.
For example, a preliminary study of about 650 H1N1 patients hospitalized in the Twin Cities showed that 5.4 percent had a diagnosis of ARDS, said Dr. Ruth Lynfield, state epidemiologist. Similar reports have come from New Zealand, Canada and Europe.
Why does it happen to some people but not others?
No one knows for sure, but one prevailing theory is that it's genetic, said Dr. Greg Poland, an infectious-disease expert at the Mayo Clinic.
Some people inherit an immune system that does not protect them from certain strains of influenza or other infections. The reverse is also true.
For example, some people can be infected with HIV, the virus that causes AIDs, and never get sick, he said.
"It's the immune response genes that they carry -- or not," he said.
At this point, Poland says, it seems not that many people are susceptible to such an extreme response to H1N1. But flu viruses are notorious for their ability to mutate, and they fear that H1N1 could morph into something lethal to more people.
Brad Lange was released from the hospital three weeks to the day after he was admitted. He left 20 pounds lighter and with a new respect for influenza. He remembers almost nothing of his stay - just the nightmares he had while sedated.
"I dreamt that I couldn't move. That things were happening to me and I couldn't do anything about it," he said.
http://www.startribune.com/lifestyle/health/virus/78612267.html?page=1&c=y