Obese Exposed as Swine Flu Collides With Fat Epidemic

[the doctor]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

I have found 44 articles in PubMed that deal with this. Here are the best abstracts I could find that relate to this issue. Apparently, rhabdo is seen with type A and B flu but is pretty rare.

GW

Influenza A and rhabdomyolysis. J Infect. 1990 Nov;21(3):303-4.
Foulkes W, Rees J, Sewry C.Department of Medicine, Royal Postgraduate Medical School, Hammersmith Hospital, London, U.K.

A case of influenza A H3N2 resulting in unusually severe rhabdomyolysis and myoglobinuria is described. Although a rare complication of viral infection, prompt treatment with intravenous fluids can prevent the serious complications which may follow.

Influenza A infection with rhabdomyolysis and acute renal failure - a potentially fatal complication Postgrad Med J (1991) 67, 389 - 390 i The Fellowship of Postgraduate Medicine, 1991 Lynn Berry and Stanley Braude
Department of Thoracic Medicine, Royal Brompton Hospital, Fulham Road, London SW3 6HP, UK

Summary: This paper describes a case of influenza A infection complicated by rhabdomyolysis and acute renal failure. This very rare complication is particularly important as symptoms may be non-specific and therefore ascribed to the underlying influenzal illness.

Introduction
Although myalgic symptoms are almost invariable in influenzal illnesses, myositis and myoglobinuria appear to be extremely rare and have been documented only in influenza A infection."2 Myalgia is usually prominent early in the illness, contrasting with available descriptions of influenza-associated myositis where onset is after or during resolution of respiratory symptoms.'`3 We present a case of influenza A infection complicated by rhabdomyolysis and acute renal failure, a syndrome described only once previously.2 This complication is particularly important because, as in this patient, its clinical presentation may be subtle, and failure to recognize it could have had fatal consequences.

Massive Rhabdomyolysis Associated with Influenza A Infection (Internal Medicine 33: 450-453, 1994) Yasuhisa Wakabayashi, Tomohito Nakano*,Takaaki Kikuno*, Takashi Ohwada* and Ryuichi Kikawada

A 20-year-old male with massive rhabdomyolysis associated with a high fever and acute renal failure is reported. Influenza A infection was confirmed serologically. Myoglobin kinetics was studied in this case. Blood myoglobin fell exponentially independent of renal function or therapeutic modality such as hemodialysis/filtration, once myoglobin release into the circulation ceased. The
finding suggested that catabolic steps ofmyoglobin take place extrarenally in patients with massive rhabdomyolysis and acute renal failure.


Brief report Rhabdomyolysis and acute renal failure in a child with influenza A infection Pediatr Nephrol (1997) 11: 363 ? 365 Katherine MacRae Dell and Seth L. Schulman Division of Nephrology, The Children?s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA Received July 16, 1996; received in revised form and accepted November 6, 1996

Abstract. A 13-year-old previously healthy girl developed rhabdomyolysis and acute renal failure during influenza A infection. The patient recovered renal function completely with supportive therapy. This complication has been described in adult patients, but progression to acute renal failure in this context has not been reported previously in children. This diagnosis should be considered in the differential diagnosis of a pediatric patient presenting with acute renal failure and viral symptomatology.


Rhabdomyolysis and Acute Renal Failure Associated with Influenza Virus Type A Scandinavian Journal of Urology and Nephrology, Volume 33, Issue 4 September 1999 , pages 260 - 264Authors: Marita Annerstedt; Hans Herlitz; Johan Mlne; Anders Oldfors; Gunnar Westberg

Abstract
Two patients with rhabdomyolysis-induced acute renal failure due to influenza A virus infection are presented. Both had influenza symptoms, with high fever and severe muscular pain leading to walking problems. In addition, they were dehydrated due to vomiting and diarrhoea. Both had evidence of an ongoing influenza infection according to serological tests. Muscle injury due to the viral infection gave rise to rhabdomyolysis with efflux of myoglobin from the muscles, causing renal failure. In conclusion, influenza A virus infection can cause rhabdomyolysis accompanied by reversible acute renal failure.

Clinical study of influenza-associated rhabdomyolysis with acute renal failure. Clin Nephrol. 2006 Sep;66(3):166-70. Abe M, Higuchi T, Okada K, Kaizu K, Matsumoto K. Division of Nephrology and Endocrinology, Department of Medicine, Nihon University School of Medicine, 30-1, Oyaguchi-Kamima chi, Itabashi-ku, Tokyo 173-0032, Japan. m_nori@yahoo.co.jp

AIMS: Influenza-associated rhabdomyolysis induces renal failure with a fatal outcome. The aim of this study is to evaluate the clinical features, diagnosis, and treatment efficacy of influenza-associated rhabdomyolysis patients with acute renal failure (ARF). MATERIALS AND METHODS: The subjects included 6 patients who had presented with rhabdomyolysis and ARF due to influenza infection on admission to our university hospital and its 2 affiliated hospitals between January 2002 and February 2004. We retrospectively examined the cases. RESULTS: All the patients (n = 6) were males, and none of them had received an influenza vaccine. The viruses were identified as influenza A (n = 5) and B (n = 1). Muscular weakness was observed in many cases (n = 5), whereas pain or tenderness was observed in only 1 case (n = 1). For anuric or oliguric patients (n = 4), blood purification therapy was performed, while for patients in whom the urine volume was normal (n = 2), conservative therapy was administered. CONCLUSION: Careful medical attention is necessary when patients have muscle pain and weakness. Early recognition of rhabdomyolysis allows prompt institution of an appropriate therapy that includes blood purification and may minimize the renal dysfunction associated with this disorder.

The use of extracorporeal life support in the treatment of influenza-associated myositis/rhabdomyolysis Perfusion, Vol. 21, No. 2, 121-125 (2006)
DOI: 10.1191/0267659106pf850oa
 Simon L Augustin
Cardiac Surgical Unit, Royal Children?s Hospital, Victoria, Australia
Cardiac Surgical Unit, Royal Children?s Hospital, Victoria, Australia, University of Melbourne, Melbourne, Australia

A 13-year-old girl presented to the emergency department with fatigue, headaches and muscle stiffness after returning from a family camping trip. Within 24 h, she was transferred to ICU with general oedema and low saturations, where she had a cardio-respiratory arrest and was placed on veno-arterial extracorporeal membrane oxygenation (ECMO). The patient was successfully supported with ECMO for profound myocardial dysfunction and haemofiltration for rhabdomyolysis and acute renal failure.
Patients who present with profound myocardial dysfunction and myoglobinuria as a consequence of viral infection can be successfully supported with ECMO.

Influenza A-associated rhabdomyolysis with acute renal failure. Dworschak AM, Wiebe B, Pohlmann U, Ehlen M, Scholer-Everts R, Bartmann P. Klin Padiatr. 2008 Jul-Aug;220(4):266-7. Department of Neonatalogy and Pediatric Intensive Care, Asklepios Children's Hospital St. Augustin, Germany.

Rhabdomyolysis induced acute renal failure as a rare complication of influenza A infection has been mainly described in adults. Consideration of this potentially life-threatening complication in pediatric patients presenting with influenza is important as clinical symptoms may be unspecific and early diagnosis leading to prompt treatment is essential to decrease associated morbidity and mortality. We report a 9 year old girl who developed severe rhabdomyolysis with myoglobinuric renal failure associated with influenza A virus infection. Receiving supportive therapy including intensive care management the patient recovered renal function completely.

 

[St Michael]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Which comes first, the rhabdomyolysis or cytokinemia? Has rhabdomyolysis been associated with cytokine storm? (I don't know.)

And if Vitamin D is sequestered in fat tissue, are the obese at higher risk due to a (relative) insufficiency of Vitamin D? Could relative Vitamin D insufficiency in the obese contribute to higher risk of cytokinemia and thus rhabdomyolysis?

 

[the doctor]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Which comes first, the rhabdomyolysis or cytokinemia? Has rhabdomyolysis been associated with cytokine storm? (I don't know.)

And if Vitamin D is sequestered in fat tissue, are the obese at higher risk due to a (relative) insufficiency of Vitamin D? Could relative Vitamin D insufficiency in the obese contribute to higher risk of cytokinemia and thus rhabdomyolysis?

The morbidly obese may well be vitamin D deficient for the reasons and data provided by Tom on the vitamin D thread and if so this places them at higher risk if our vitamin D hypothesis is correct.

The etiology of the rhabdo in patients with flu is a new and interesting question but not one that is likely due to vitamin D directly but it does play an important role in muscle health so we can not count our this possibility.

If you read the article abstracts, only one group thought the virus was directly causing the muscle breakdown while all the others simply reported it in association with influenza infection. The answer then is we do not know.

The fact that all 10 of the men in the Michigan series had elevated levels of CPK is very interesting in this regard. However most had DVT and PE, conditions associated with increased levels of rhabdo which some could argue was the cause rather than flu.

Many in this case series also had renal failure and were probably kept "dry" do to their ARDS. Although we do not know this. Someone should email one or more of the authors of this report and ask them to come here and comment on this. They were there and know what happened, we do not.

So, being hypovolemic and having rhabdo would mean that even a low level rhabdo could cause renal failure under these circumstances.

The other issue is was there any evidence of direct infection of the kidney by the virus in those with renal failure. This hypothesis has been expressed before as the reason pandemic influenza patients experienced acute renal failure. Again, the report's authors may have clinical or autopsy information about this that could be enlightening.

If rhabdo is directly due to flu and is more common in pandemic flu than seasonal flu then this is exciting new territory because monitoring for it and when identified, addressing it swiftly, could help many severely ill people survive their infection by avoiding renal failure.

However, an observation like this is of interest but proof of nothing. What is needed first is for individual practitioners to check for these conditions and if found address them appropriately. If the outcomes from these one off uses are positive and they are reported in the medical literature or even by word of mouth then these results would constitute what is known as anecdotal reports, a low level of scientific evidence because there are many sources of error and bias that can effect the outcomes.

However, if the anecdotes are encouraging, then formal study of the intervention is warranted, especially given that our options for dealing with this virus are pretty limited. If the results of formal studies confirm the benefit of the intervention then it is likely to be advocated by TPTB which will cause it to become widespread.

This is how it goes in scientific medicine and there are very important reasons that this rather bureaucratic process be followed. Without subjecting each and every "good idea" to this type of scrutiny, what really works and what doesn't can not be determined. This process is the essence of scientific or allopathic medicine. I support this process because over my time as a medical practitioner, I have seen the value of evidenced based medicine. It does take a long time for new ideas to prove themselves but by the time they make their way through this gauntlet, if they are upheld, then they soon become the consensus practice.

On FTs we speak of many potential ways to deal with pandemic flu. The vitamin D hypothesis is but one example. While some of us have accepted this hypothesis as fact, this is not the case with the vast majority of those within the US FDA, the CDC or the community of treating physicians. The same is true with regard to the possibility that rhabo may be more common than expected in patients with pandemic flu and this disorder could be responsible for renal failure seen in at least some of these patients.

At the very least, the evidence suggests to me that all doctors caring for severely ill novel strain patients should be checking their patient's 25 OH vit D and CPK levels.

Hospitals run CPK levels quite often during the day but vitamin D levels are not run promptly. For this reason, if I was treating a person severely ill with pandemic flu, I would give them 50,000iu of vitamin D2 either orally or IM ASAP after the serum vit D level was drawn. There is no risk of doing this and if vit D replacement can help the acutely ill, the sooner it is given the better.

Checking a patient's 25 OH vit D level is easy to do and relatively cheep. The same applies to the serum CPK. Treating physicians aware of the literature research we have reported on this site may indeed take advantage of the recommendations we have made here without fear of harming their patients.

Since 99.9% of treating physicians do not visit FTs, they will not know of what we have discovered and recommend. For them to become aware require TPTB to adopt these recommendations which will not happen until they are proven correct in clinical trials. So, don't hold your breath.

Nevertheless, these notions regarding rhabdo and 25 OH vit D deserve to be examined in severely ill patients hospitalized right this minute with flu. Especially those in the ICU.

Here are some questions that need answers:

What are their CPK levels? What are their 25 OH vit D3 levels?

Is the high incidence of renal failure seen among pandemic influenza victims related to unsuspected rhabdo or not?

Are the outcomes different between patients with 25 OH vit D3 levels above 50ng/ml compared with those under the immune health threshold different?

Does supplementation with lots of vitamin D3 at the onset of influenza result in better outcomes?

Does supplementation with lots of vitamin D3 before contracting influenza have an effect on outcomes?

These are the questions that need to be answered and in my view quickly. The answers can be obtained pretty fast. The cost to do so is low. The potential benefit is very high and there is very little reason why treating physicians should not at least ask them even if they do not act on them immediately.

GW

 

[somebodyoutthere]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

I do have some critical comments to make about this case report and that is how outragious it was. It was truly an example of public health muck racking of the first order. On the CDC's public enemies list is obesity right up there with smoking. They just could not resist publishing this report as a way to get in a blow against fat people.

Thank you for stating this--ever since this story broke, I've wanted to put that thought into words.

 

[the doctor]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Thank you for stating this--ever since this story broke, I've wanted to put that thought into words.

Your welcome and thank you for recognizing the social justice of my criticism.

GW

 

[St Michael]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

If you read the article abstracts, only one group thought the virus was directly causing the muscle breakdown while all the others simply reported it in association with influenza infection. The answer then is we do not know.

The fact that all 10 of the men in the Michigan series had elevated levels of CPK is very interesting in this regard. However most had DVT and PE, conditions associated with increased levels of rhabdo which some could argue was the cause rather than flu.

Acute renal failure frequently occurs as a complication of multiple organ dysfunction, right?

Can DVT and PE be due to Disseminated Intravascular Coagulation (DIC), a late complication of multi-organ failure and cytokinemia?

What we need is longitudinal studies of cytokine levels throughout the clinical course of these H1N1 infections, so we can correlate which came first, the cytokinemia or the respiratory and renal failure, rhobdo, enchephalitis, GI symptoms, DVT/PE, etc.

I still suspect that systemic circulation of cytokines due to immune response is responsible for the vast majority of sequella we are seeing in all these reports.

 

[wotan]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Thank you for stating this--ever since this story broke, I've wanted to put that thought into words.

Thank you as well, Dr. I have stated several times here and elsewhere that I do not believe being obese can, in and of itself, predispose people to more severe cases of flu. It is possible to be obese and still be in reasonably good health. Look at the average offensive lineman in the NFL. These are 300+lb behemoths but they are physically active and likely would classify in all other ways as healthy.

For myself, yes, I am obese, but I have no medical conditions linked to it. My blood pressure is fine (not diagnosed pre-hypertensive, despite history in both sides of my family), my blood sugar is fine (not diagnosed pre-diabetic despite family history), my blood chemistry is fine, etc. I am out of shape (but that is more related to having a desk job), but I don't consider myself unhealthy. The only condition I have that really can be linked to my weight is a herniated disc, but even that isn't necessarily weight-related.

For my flu risk I am much more concerned with my age, being 32 I am still a prime candidate for cytokine storm. I have received the pneumococcal pneumonia vaccine (as has all of my family) so I am not concerned there, but I am terribly concerned that at least one of us will wind up in the hospital in the next several months due to this, since my wife and I are young enough to deal with cytokine storms, one child will soon be 6 and so I think moving into that age range, and the 3 year old has a bonafide respiratory condition (cystic fibrosis) and I don't believe a safe, effective vaccine will be available until nest year at the earliest.

 

[AlaskaDenise]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

These are the questions that need to be answered and in my view quickly. The answers can be obtained pretty fast. The cost to do so is low. The potential benefit is very high and there is very little reason why treating physicians should not at least ask them even if they do not act on them immediately.

This lack of communication and information sharing is unbelievable.

If we were asking questions about profit margins, investment returns, etc., the answers would be at your fingertips.

.

 

[AlaskaDenise]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

The entry from Medical Encyclopedia above lists deep vein thrombosis as a possible cause of rhabdo and most of the gents had this, so this might be the reason rather than a direct effect of the flu. I will keep looking.

GW

Within the context of these concerns, can we say that those getting this flu should stay well hydrated - to prevent the DVT, etc.? You said that some of these conditions were aggravated in ICU, by the SOP of keeping them "dry" - so that's why it appears to me that adequate hydration from the start is extra important.

.

 

[AlaskaDenise]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

If Dr. Fedson is correct that one complication of obesity is increased inflammation, can that be mitigated by an anti-inflammation diet or supplement, e.g., curcumin/turmeric ?

.

 

[the doctor]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Within the context of these concerns, can we say that those getting this flu should stay well hydrated - to prevent the DVT, etc.? You said that some of these conditions were aggravated in ICU, by the SOP of keeping them "dry" - so that's why it appears to me that adequate hydration from the start is extra important.

.

ARDS is a syndrome not a disease. A syndrome is a common clinical presentation that occurs as a result of many causes. ARDS is known to complicate many medical and surgical conditions and we really don't know why it happens in most cases.

Cytokine storm caused by immune dysregulation as the etiology of ARDS in patients with influenza then says a lot. If the above sentence is true, then we know a lot more about ARDS in flu patients than we do about it in most other conditions.

Now, since ARDS has different causes and each unique cause would be expected to set into motion a specific turn of events that results in ARDS, then maybe it would be possible to intervene early in the course before ARDS has developed to prevent it. Vitamin D is one such pre-influenza infection intervention that might be useful here by helping to prevent immune system dysregulation. It might even be useful when given post-influenza acquisition but before the development of ARDS if administered IM or orally as D2 or D3 in high dose (50,000 to 150,000 iu).

The question is though what to do once ARDS is already present? The article stated that cases they were familiar with from Latin American did not mention DVT or PE. These adverse events could then be due to obesity alone but were aggravated by keeping them dry. Since the cause of the ARDS in flu patients is better understood than in most other causes of ARDS, maybe some doctor's should try high IV fluid rates in a few patients and see if this reduces the incidence of renal failure and possibly liver insufficiency. It may be that these patients might do better than others with ARDS due to unrelated conditions.

Another possibility is to run the patient's serum through filters designed to sequester pathogenic cytokines from the victims blood. This would include TNF and some of the interleukins as well as others but we would need to do this wisely, not removing them all but enough of them to resort balance within the immune system but not too much that would put them at risk for other infections.

Basically, what I am saying is that presently all cases of ARDS are treated very similarly but maybe some cases should be treated differently than others and flu as the cause could be one of them.


Grattan Woodson, MD

 

[rossi]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

These 300 pounders are not healthy in all other ways. A NEJM report in 2003 showed that they had a significant amount of sleep apnea. Of the linesman 14% had sleep apnea, whereas 4% would be found in men in general population. Research in the area of sleep apnea is showing that an inflammmatory response may be responsible for cardiac disease. It's a long leap to having anything to do with severity of influenza but obesity is associated with sleep apnea. There is a lot we don't know!

Thank you as well, Dr. I have stated several times here and elsewhere that I do not believe being obese can, in and of itself, predispose people to more severe cases of flu. It is possible to be obese and still be in reasonably good health. Look at the average offensive lineman in the NFL. These are 300+lb behemoths but they are physically active and likely would classify in all other ways as healthy.

For myself, yes, I am obese, but I have no medical conditions linked to it. My blood pressure is fine (not diagnosed pre-hypertensive, despite history in both sides of my family), my blood sugar is fine (not diagnosed pre-diabetic despite family history), my blood chemistry is fine, etc. I am out of shape (but that is more related to having a desk job), but I don't consider myself unhealthy. The only condition I have that really can be linked to my weight is a herniated disc, but even that isn't necessarily weight-related.

For my flu risk I am much more concerned with my age, being 32 I am still a prime candidate for cytokine storm. I have received the pneumococcal pneumonia vaccine (as has all of my family) so I am not concerned there, but I am terribly concerned that at least one of us will wind up in the hospital in the next several months due to this, since my wife and I are young enough to deal with cytokine storms, one child will soon be 6 and so I think moving into that age range, and the 3 year old has a bonafide respiratory condition (cystic fibrosis) and I don't believe a safe, effective vaccine will be available until nest year at the earliest.

 

[Sally Furniss]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

Welcome rossi

 

[AlaskaDenise]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

........, maybe some doctor's should try high IV fluid rates in a few patients and see if this reduces the incidence of renal failure and possibly liver insufficiency. It may be that these patients might do better than others with ARDS due to unrelated conditions. ........

So, you're saying there is no benefit to the average mild H1N1 case staying any more hydrated than they would with any illness?

But sitting outside in the sun would be good? (in addition to Vit D supplements)

.

 

[the doctor]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

So, you're saying there is no benefit to the average mild H1N1 case staying any more hydrated than they would with any illness?

But sitting outside in the sun would be good? (in addition to Vit D supplements)

.

No. The everyone with flu should concentrate on staying well hydrated first and foremost. The patients that were the subject of this report were not usual. They were extreme. They had ARDS, a condition where high fluid inputs in the past have increased mortality.

Yes, and vitamin D might help.

GW

 

[KBD]

Re: Obese Exposed as Swine Flu Collides With Fat Epidemic

so it looks like morbid obesity IS an independent risk factor afterall. http://www.flu.gov/news/blogs/obesityh1n1study.html