Postvaccination Influenza 2009 H1N1 Respiratory Failure Requiring Extracorporeal Membrane Oxygenation

[tetano]

Case Reports in Infectious Diseases
Volume 2011 (2011), Article ID 167963, 2 pages
doi:10.1155/2011/167963Case ReportPostvaccination Influenza 2009 H1N1 Respiratory Failure Requiring Extracorporeal Membrane OxygenationMichael S. Firstenberg,1 Erik Abel,1 Danielle Blais,1 Juan Crestanello,1 and Julie E. Mangino21Division of Cardiac Surgery, The Ohio State University Medical Center, Columbus, OH 43210, USA
2Division of Infectious Diseases, The Ohio State University Medical Center, Columbus, OH 43210, USAReceived 11 August 2011; Accepted 3 October 2011Academic Editors: W. Chierakul, A. Mangano, and A. R. MarraCopyright ? 2011 Michael S. Firstenberg et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractThe spread of pandemic Influenza A (H1N1-2009) was believed to have been attenuated by the effectiveness of worldwide vaccination initiatives. Despite the immunogenicity of a safe vaccine, we report a case of vaccine failure resulting in catastrophic influenza-associated respiratory failure. Pandemic Influenza A (H1N1-2009) was not only distinguished by a predilection towards relatively young and otherwise healthy patients, but was also associated with a high incidence of catastrophic respiratory failure requiring extracorporeal membrane oxygenation (ECMO) [1, 2]. The rapid development and distribution of an effective vaccine was attributed to attenuating what was already a pandemic outbreak. Nevertheless, even in 2011, H1N1-2009 continues to be a challenging clinical and epidemiologic problem. H1N1-2009 vaccination was determined to be >95% effective within 3 weeks in otherwise healthy adults [3, 4]. While serious infections in vaccinated patients have been reported [5], many of these patients have risk factors for vaccination failure?such as chronic institutionalization or disabled and debilitated patients who may lack a functional immune system?and the ?severity? of illness is debatable. We present a case of a previously healthy male, with documented vaccination and a sufficient lag time to develop an appropriate antibody response, in which severe H1N1-2009-associated respiratory failure developed requiring ECMO.Our patient was a 53-year old previously healthy, nonsmoker with no reported unusual recent exposures, male who presented to an outside hospital with severe respiratory distress. He was started on empiric broad-spectrum antibiotics and oseltamivir phosphate (150 mg PO BID, Tamiflu, Genentech, Inc., San Francisco, Calif, USA) and Methylprednisolone (60 mg intravenous, Q6H for 3 days). Initial bacterial blood and respiratory cultures were negative, but had a positive nasal swab for Influenza H1N1. Initial chest X-ray showed severe diffuse pulmonary infiltrates and edema consistent with adult respiratory distress syndrome (ARDS, Figure 1). Five days later, due to failure of maximal mechanical ventilation and worsening hypoxemia with hypercarbia he was placed on percutaneous veno-veno ECMO and transferred to our Institution. Upon arrival, bacterial and fungal blood, urine, and respiratory cultures from a bronchial alveolar lavage were obtained and were negative. Real-time polymerase chain reaction assay was positive for H1N1-2009. Other viral cultures, including HIV-1/-2 and a hepatitis panel, were negative. A transthoracic echocardiogram was unremarkable. Over several days, antibiotic therapy was deescalated, and he completed a 10-day course of oseltamivir.

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http://www.hindawi.com/crim/id/2011/167963/

 

[Emily]

Re: Postvaccination Influenza 2009 H1N1 Respiratory Failure Requiring Extracorporeal Membrane Oxygenation

The paper says that risk factors including smoking were not present in this patient who got severe influenza 2 months after confirmed vaccination. I just wish environmental factors were looked at more closely in studies. I wonder about the patient's exposure to woodsmoke since it sounds like he got ill early in the winter of 2011. Studies are showing that woodsmoke shares many of the the same risks as tobacco smoke. And we have discussed some research suggesting that arsenic exposure could increase susceptibility to H1N1. Unfortunately there are people who burn scrap wood for heat that might be treated with arsenic containing preservatives. Somebody might not even know they were exposed if a neighbor is doing that.

I also wondered about other environmental exposures he might have had at work, or at home to remodeling paints and chemicals. I believe I remember one healthy younger woman dying from the first wave of the 2009 H1N1 pandemic flu, and the mainstream news article mentioned she had just completed a home remodeling project prior to catching the flu.