Interesting post-mortem findings in a H1N1 influenza-positive pneumonia patient

Reports of histopathological findings in a patient infected with H1N1 influenza virus are limited in the literature, although many deaths have occurred because of this viral infection. In an otherwise healthy individual with no underlying co-morbid conditions, this virus passes off as a very mild disease. However, it can be fatal in the presence of underlying risk factors. Here, we present the autopsy findings of a patient who died of H1N1 infection, but who was apparently healthy with no predisposing ailments. The autopsy revealed chronic kidney disease and caseating granulomatous lymphadenitis in addition to the known classical diffuse alveolar damage picture seen in this condition. These underlying co-morbidities may provide greater insight and a better understanding of this infection.

Efeito da exposição à hidroquinona na resposta imune adaptativa induzida pela vacina contra a influenza / Effects of hydroquinone exposure on the adaptive immune response induced by the influenza vaccine

A gripe é causada pelo vírus Influenza e é um problema de saúde pública mundial, que pode levar a problemas sérios em idosos e crianças. O Brasil implantou a vacinação anual contra influenza a partir de 1999, como ação preventiva contra a doença. A vacina é produzida pelo Instituto Butantan e contém três cepas diferentes do vírus Influenza fragmentado para induzir resposta imune adaptativa, com produção de anticorpos específicos e neutralizantes. A literatura tem mostrado que a exposição à xenobióticos com potencial imunossupressor pode comprometer a eficácia de imunizações ativas, como a imunização contra a gripe. Nosso grupo de pesquisa tem mostrado que a exposição à hidroquinona (HQ), um composto tóxico presente em altas concentrações na fumaça do cigarro, prejudica a resposta imune inata e adquirida. Assim, este trabalho avaliou o efeito da exposição à HQ sobre a resposta imune à vacinação contra influenza. Camundongos machos da linhagem C57BL/6 foram diariamente expostos à HQ (2500 ppm) ou PBS, por 1 hora, por nebulização, por um período de 8 semanas. Durante este período, foram imunizados nas semanas 6 e 8 do início das exposições, pela injeção i.m. de 100µL da vacina. Os parâmetros tóxicos e imunológicos foram avaliados 7, 35 e 70 dias após a segunda dose da vacina. A exposição à HQ não alterou o peso corpóreo dos animais e nem causou alterações morfológicas no pulmão, fígado e rins (histologia por H&E); reduziu a frequência de hemácias (11%), hematócrito (14%), hemoglobina (14%) e volume celular (4%); causou estresse oxidativo no baço (citometria de fluxo); aumentou a área dos folículos de células B no baço e linfonodomegalia (histologia por H&E). Em conjunto, os dados aqui obtidos mostram que a exposição à HQ afetou mecanismos envolvidos na gênese da imunidade ativa contra influenza. Assim, os dados deste trabalho mostram mecanismos tóxicos ainda não descritos para a HQ, e ressalta a HQ como um poluente ambiental que deve ser considerado nas avaliações de risco

The flu is a health problem worldwide which is caused by the Influenza virus and may result in severe illness in infants and the elderly. The annually vaccination against influenza was implemented in Brazil in 1999 as a preventive measure. The vaccine is produced by Butantan Institute and contains three different strains of the inactivated Influenza virus which induce the adaptive immune response along with production of specific and neutralizing antibodies. The literature has shown that exposure to immunosuppressive xenobiotics may compromise the efficacy of active immunizations, such as influenza. Our research group has shown that exposure to hydroquinone (HQ), a toxic constituent of cigarette smoke, impairs both innate and adaptive immune response. Thus, the aim of this work was to evaluate the effects of HQ on the immune response induced by the influenza vaccine. Male C57BL/6 mice were daily exposed to HQ (2500 ppm) or PBS by nebulization, for 1 hour, for 8 weeks. During the exposure period, the animals were vaccinated on weeks 6 and 8 with 100µL of the vaccine. Toxicologic and immunological parameters were assessed 7, 35 and 70 days after boost administration. HQ exposure did not alter body weight and did not cause morphological alterations in the lungs, liver and kidneys (H&E staining); reduced the frequency of erythrocytes (11%), hematocrit (14%), hemoglobin (14%) and cellular volume (4%) and caused oxidative stress on the spleen (Flow Cytometry); increased the area of B cell follicles in the spleen and increased the size of draining lymph nodes (H&E staining). Altogether, these data show that HQ exposure affected mechanisms involved in the genesis of the adaptive immune response. Thus, the data presented in this work show toxic mechanisms of HQ that have not yet been described, and it also points out HQ as an environmental pollutant which should be considered on risk assessments

The influenza season 2016/17 in Bucharest, Romania - surveillance data and clinical characteristics of patients with influenza-like illness admitted to a tertiary infectious diseases hospital

ABSTRACT Background: Influenza continues to drive seasonal morbidity, particularly in settings with low vaccine coverage. Objectives: To describe the influenza cases and viral circulation among hospitalized patients. Methods: A prospective study based on active surveillance of inpatients with influenza-like illness from a tertiary hospital in Bucharest, Romania, in the season 2016/17. Results: A total of 446 patients were tested, with a balanced gender distribution. Overall, 192 (43%) patients tested positive for influenza, with the highest positivity rate in the age groups 3-13 years and >65 years. Peak activity occurred between weeks 1 and 16/2017, with biphasic distribution: A viruses were replaced by B viruses from week 9/2017; B viruses predominated (66.1%). Among the 133 (69.3%) subtyped samples, all influenza A were subtype H3 (n = 57) and all influenza B were B/Victoria (n = 76). Patients who tested positive for influenza presented fewer comorbidities (p = 0.012), except for the elderly, in whom influenza was more common in patients with comorbidities (p = 0.050). Disease evolution was generally favorable under antiviral treatment. The length of hospital stay was slightly longer in patients with influenza-like illness who tested patients negative for influenza (p = 0.031). Conclusions: Distinctive co-circulation of A/H3 and B/Victoria in Bucharest, Romania in the 2016/17 influenza season was found. While the A/H3 subtype was predominant throughout Europe that season, B/Victoria appears to have circulated specifically in Romania and the Eastern European region, predominantly affecting preschoolers and school children.

Impact of A/H1N1 influenza in children at a Brazilian University Hospital

ABSTRACT Background A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.

Intervenciones de enfermería para la atención en adultos de 65 años y más con infecciones de vías respiratorias en el primero y segundo nivel de atención / Nursing interventions for care in adults 65 years and older with respiratory tract infection in the first and second level of care

OBJETIVO: Establecer intervenciones de enfermería efectivas para la atención de los adultos de 65 años y más con infecciones de vías respiratorias, para disminuir la incidencia de morbilidad y mortalidad y mejorar la calidad para contribuir a garantizar la seguridad de la atención y el autocuidado.MATERIALES Y MÉTODOS: Elaboración de las preguntas a responder y conversión a preguntas clínicas estructuradas, búsqueda y revisión sistemática de la literatura: recuperación de guías internacionales o meta análisis, o ensayos clínicos aleatorizados, o estudios observacionales publicados que den respuesta a las preguntas planteadas, de los cuales se seleccionarán las fuentes con mayor puntaje obtenido en la evaluación de su contenido y las de mayor nivel en cuanto a gradación de evidencias y recomendaciones.Protocolo sistematizado de búsqueda: Algoritmo de búsqueda reproducible en bases de datos electrónicas, en centros elaboradores o compiladores de guías, de revisiones sistemáticas, meta análisis, en sitios Web especializados y búsqueda manual de la literatura.RESULTADOS Y DISCUSIÓN: Un total de fuentes documentadas y utilizadas: 81 (Pud Med, BVS, TRIPDATA BASE, Otros sitios Web). guías seleccionadas: 4, revisiones sistemáticas: 26, ensayos clínicos aleatorizados: 14, meta análisis: 17, estudios de cohorte: 6, casos y controles: 5 y otros documentos: 9.CONCLUSIONES: La vacunación contra la influenza a los grupos más vulnerables y el constante lavado de manos, son algunas de las intervenciones que contribuyen a la prevención y control de las enfermedades respiratorias en los adultos mayores.

OBJECTIVE: Establish effective nursing interventions for the care of adults 65 years and older with respiratory tract infections, to reduce the incidence of mordidito and mortality and improve quality to help ensure the safety of care and self-care.MATERIALS AND METHODS:Development of questions to answer and conversion to questions structured clinical, research and systematic review of the literature: recovery of international or meta guides analysis or randomized clinical trials, or published observational studies that respond to the questions, of which will select the sources with the highest score obtained in the evaluation of its content and the higher level as to grading evidence and recommendations.Search systemized protocol: search algorithm reproducible electronic databases, in institutions or compilers processors guides, systematic reviews, meta analysis, specialized Web sites and manual literature search.RESULTS AND DISCUSSION:A total of documented and used sources: 81 (Pud Med, BVS, TRIPDATA BASE, Other Web sites). Selected guides: 4, systematic reviews: 26 randomized clinical trials: 14, meta analysis: 17 cohort studies: 6 cases and controls 5 and other documents: 9.CONCLUSIONS: Influenza vaccination the most vulnerable groups and constant hand washing, are some of the interventions that contribute to the prevention and control of respiratory diseases in older adults.

OBJETIVO: Estabelecer intervenções eficazes de enfermagem para o cuidado dos adultos com 65 anos e mais velhos com infecções do trato respiratório, para reduzir a incidência de morbidade e mortalidade e melhorar a qualidade para ajudar a garantir a segurança dos cuidados e auto-cuidado.MATERIAIS E MÉTODOS:Desenvolvimento de perguntas para responder e conversão às perguntas estruturadas clínica, pesquisa e revisão sistemática da literatura: a recuperação da análise de guias internacionais ou meta ou ensaios clínicos randomizados, ou publicados estudos observacionais que respondam às perguntas, das quais irá selecionar as fontes com o maior resultado obtido na avaliação do seu conteúdo e do nível superior como a classificação de evidências e recomendações.Pesquisar protocolo sistematizado: algoritmo de busca bases de dados electrónicas reprodutíveis, em instituições ou compiladores processadores guias, revisões sistemáticas, meta-análise, sites especializados e busca manual de literatura.RESULTADOS E DISCUSSÃO:Um total de fontes documentados e usados: 81 (Pud Med, BVS, TRIPDATA BASE, outros sites). guias selecionadas: 4, revisões sistemáticas: 26 ensaios clínicos randomizados: 14, meta-análise: estudos de coorte 17: 6 casos e controles 5 e outros documentos: 9.CONCLUSÕES: Vacinação contra a Gripe dos grupos mais vulneráveis e a lavagem das mãos constante, são algumas das intervenções que contribuam para a prevenção e controlo de doenças respiratórias em adultos mais velhos.

Muscle biopsy features in critical ill patients with 2009 influenza A (H1N1) virus infection / Alterações da biópsia muscular em pacientes gravemente acometidos pela infecção por vírus influenza A (H1N1) 2009

Higher serum creatine kinase (CK) levels in critically ill patients with a confirmed 2009 influenza A (H1N1) infection suggests a possible relationship between the H1N1 virus and muscle tissue. However, there have been no reports with an emphasis on muscle biopsies for patients infected with the H1N1 virus. The objective of this study was to investigate the histological characteristics of the muscle biopsies from critically ill patients with confirmed 2009 H1N1 infections. A series of ten patients with confirmed 2009 H1N1 infection, who presented increased serum CK levels, was analyzed. Histological study found small histochemical alterations in muscles fibers (mainly in NADH, SDH, COX, myophosphorylase, adenylate deaminase and PAS stains), and no histological changes were compatible with inflammatory myopathy. Although our critically ill patients had elevated CK levels, they exhibited few histological/histochemical abnormalities in their muscle biopsy samples; however, those alterations could be consistent with metabolic dysfunction associated with influenza H1N1 infection.

Os elevados níveis séricos da creatina quinase (CK) em pacientes gravemente acometidos pela infecção por influenza A (H1N1) 2009 sugerem uma possível relação entre infecção pelo vírus H1N1 e alterações do tecido muscular. No entanto, não existem relatos com ênfase nas alterações histológicas encontradas no músculo dos pacientes infectados pelo vírus H1N1. O objetivo deste estudo foi investigar as características histológicas, em biópsia muscular, de pacientes gravemente acometidos pela infecção por vírus H1N1 2009. Foi analisada uma série de dez pacientes com infecção confirmada por vírus H1N1, que apresentavam nível sérico elevado de CK. O estudo histológico evidenciou pequenas alterações histoquímicas nas fibras musculares (mais evidentes nas colorações por NADH, SDH, COX, miofosforilase, adenilato deaminase e PAS) mas sem alterações histológicas compatíveis com miopatia inflamatória. Embora nossos pacientes mostrassem níveis séricos elevados de CK, foram poucas as alterações histológicas e histoquímicas encontradas em suas biópsias musculares. Contudo, essas alterações podem ser consistentes com uma disfunção metabólica da fibra muscular associada à infecção pelo H1N1.

Influenza A H1N1: características clínico-epidemiológicas de 26 pacientes hospitalizados en Hospital Regional de Talca / Influenza A (H1N1): clinical and epidemiological features of 26 patients hospitalized at Hospital Regional de Talca

Se presenta una revisión de los casos hospitalizados con influenza A H1N1 en el Hospital Regional de Talca, con el objetivo de caracterizar la forma de presentación de la enfermedad en nuestro medio. Material y método: revisión retrospectiva de ficha de 26 pacientes confirmados con PCR para influenza A H1N1, por el Instituto de Salud Pública. Se tabuló los datos de interés epidemiológico, la presentación clínica de la enfermedad, su evolución y el resultado de exámenes realizados. Resultados: Los pacientes hospitalizados representan al 2,4 por ciento de los tratados ambulatoriamente. El 69 por ciento de los casos eran mujeres, el 77 por ciento eran menor de 50 años, y el 77 por ciento tenía patología previa. El IFI resultó positivo sólo en 23 por ciento de los confirmados. Los síntomas predominantes fueron tos y fiebre. El 92 por ciento utilizó antibióticos y el 31 por ciento requirió ingreso a Unidad de pacientes Crítico. Hubo cuatro fallecidos, tres de los cuales tenían patologías previas (leucemia, lupus y cardiopatía congénita operada). Discusión: Se observó que un bajo porcentaje de pacientes requirieron hospitalización y éstos eran principalmente jóvenes, presentaban la sintomatología clásica, la evolución tórpida estuvo determinada por sobreinfección bacteriana y padecían con frecuencia de patología previa, hallazgos reportados también por otros centros nacionales.

Pathological and ultrastructural analysis of surgical lung biopsies in patients with swine-origin influenza type A/H1N1 and acute respiratory failure

BACKGROUND: Cases of H1N1 and other pulmonary infections evolve to acute respiratory failure and death when co-infections or lung injury predominate over the immune response, thus requiring early diagnosis to improve treatment. OBJECTIVE: To perform a detailed histopathological analysis of the open lung biopsy specimens from five patients with ARDS with confirmed H1N1. METHODS: Lung specimens underwent microbiologic analysis, and examination by optical and electron microscopy. Immunophenotyping was used to characterize macrophages, natural killer, T and B cells, and expression of cytokines and iNOS. RESULTS: The pathological features observed were necrotizing bronchiolitis, diffuse alveolar damage, alveolar hemorrhage and abnormal immune response. Ultrastructural analysis showed viral-like particles in all cases. CONCLUSIONS: Viral-like particles can be successfully demonstrated in lung tissue by ultrastructural examination, without confirmation of the virus by RT-PCR on nasopharyngeal aspirates. Bronchioles and epithelium, rather than endothelium, are probably the primary target of infection, and diffuse alveolar damage the consequence of the effect of airways obliteration and dysfunction on innate immunity, suggesting that treatment should be focused on epithelial repair.

Clinical characteristics of 74 pandemic HlNl influenza patients from Turkey. Risk factors for fatality

To evaluate the clinical characteristics and certain risk factors that may be associated with fatal outcome in patients with HlNl influenza. This retrospective study was conducted between October and December 2009 in the Department of Infectious Diseases and Clinical Microbiology, SB Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey. Data regarding the epidemiological and clinical characteristics of 74 hospitalized cases of confirmed pandemic HlNl influenza were reviewed. The median age was 49 [18-83] years, and 34 [46%] were males. The most common symptom and signs on admission were cough [91.9%] and fever >38°C [71.7%]. More than two-thirds of patients [68.9%] had at least one underlying condition; most frequently chronic respiratory disease, including asthma and diabetes. Seventy-seven percent had evidence of pneumonia on their chest x-rays at presentation. Of the 74 cases, 16 [21.6%] were followed up in the Intensive Care Unit, and 10 [13.5%] died. Obesity and oxygen saturation below 92% at the time of admission were found to be significantly related with fatal outcome. In addition, fatal patients had significantly higher levels of alanine aminotransferase [ALT], aspartate aminotransferase [AST], lactate dehydrogenase [LDH], urea, creatinine, d-dimer on admission and prothrombin time [PT], activated partial thromboplastin time, and the international normalized ratio [INR] was longer. Timely identification and management of patients with higher risk for fatality may improve outcomes

Manifestaciones clínicas de la infección por virus influenza en niños inmunocompetentes / Clinical manifestation of influenza virus infection in immunocompetent children

Las manifestaciones clínicas de la infección por virus influenza en niños son inespecíficas. Recientes publicaciones han revelado el impacto -en términos epidemiológicos- de esta infección en niños, incluso con tasas superiores a los adultos. Los niños sanos representan un importante grupo de riesgo. Las manifestaciones clínicas son de inicio brusco caracterizadas por la presencia de fiebre. Los niños pequeños no presentan el cuadro clínico clásico, revelando un compromiso variable del estado general, con deshidratación y convulsiones. Si bien las complicaciones respiratorias son las más frecuentes (siendo el Streptococcus pneumoniae el agente mas importante) existe un sin número de reportes que describen otros órganos y sistemas comprometidos. Este artículo revisa las principales manifestaciones en niños inmunocompetentes.

Brote de infección respiratoria aguda en una escuela primaria de Ciudad de La Habana / acute respiratory infection and overpopulation in the school of city Havana (arreglar)

La Influenza es una enfermedad febril aguda, que ocurre en forma de brotes anuales de intensidad variable. El virus infecta el aparato respiratorio, es altamente transmisible y al principio produce síntomas sistémicos importantes. Nuestro objetivo es describir el brote de Infecciones Respiratorias Agudas (IRA) ocurrido en una escuela primaria del área Santiago de las Vegas, Municipio Boyeros, Ciudad de la Habana. Se realizó el estudio del brote ocurrido en el mes de junio del 2005; se entrevistaron alumnos, profesores y padres de los niños que enfermaron; se tomaron muestras para estudio serológico y virológico; se realizó la inspección sanitaria estatal y con estos datos se describieron algunas variables clínico-epidemiológicas. Como resultado obtuvimos que enfermaron 78 niños y 4 profesores para una tasa de ataque de 33,8 y 10,8 por ciento respectivamente. El síntoma más frecuente fue la fiebre y la tos. Los resultados de laboratorio arrojaron Influenza A (H3N2). Concluimos que el hacinamiento fue un factor de riesgo.

Background: Influenza is an acute febrile illness that occurs in form of annual outbreaks of variable intensity. The virus infects the respiratory apparatus, it is highly transmissible and at the beginning it produces important systemic symptoms. Objective: To describe the IRA outbreak occurred at a primary school on Santiago de las Vegas area, Boyeros municipality, City of Havana. Method: A study of the outbreak ocurred on June 2005, interviewing students, professors and parents of the infected children, taking samples for a serological and virological study. An state sanitary inspection was made, and with this information some clinical-epidemiological variables were described. Results: A total of 78 children and 4 professors were infected, for an attack rate of 33,8 and 10,8 percent respectively. The most frequent symptoms were fever and cough. The laboratory results showed Influenza A (H3N2). Conclusions: Overpopulation was found as a risk factor.

Encefalitis equina venezolana: comentarios acerca de la epidemia ocurrida en el Estado Zulia: Venezuela a fines de 1969 / Venezuelan equine encephalitis: comments about a new outbreak in Zulia State: Venezuela in 1969

Se describe y analiza una epidemia de Encefalitis equina Venezolana ocurrida en el Estado Zulia a fines de 1969. Se considera que, a pesar de los problemas diagnósticos que se presentaron debido a que coincidió con una epidemia de influenza, la enfermedad atacó principalmente a aquellas áreas que no habían sido afectadas por la epidemia de 1968. Hubo un total de 2714 casos humanos con 13 muertes atribuíbles a la enfermedad. La morbilidad varió entre 2 y 27 por mil habitantes. La zona epidémica de la Guajira tuvo la tasa de letalidad más alta, probablemente debido a que la enfermedad afectó principalmente a los que escaparon a la anterior epidemia. La uniformidad conque la población de San Rafael de Mara fue afectada, sin especificidad de edad, hace suponer que ella no representa una zona endémica. Se reporta, por primera vez en Venezuela, mortalidad en caprinos, probablemente debida al agente viral, aunque éste no pudo ser aislado en las escasas muestras examinadas