Background. Experience from treating patients with Spanish influenza and influenza A(H5N1) suggested that convalescent plasma therapy might be beneficial. However, its efficacy in patients with ...severe pandemic influenza A(H1N1) 2009 virus (H1N1 2009) infection remained unknown. Methods. During the period from 1 September 2009 through 30 June 2010, we conducted a prospective cohort study by recruiting patients aged ≥ 18 years with severe H1N1 2009 infection requiring intensive care. Patients were offered treatment with convalescent plasma with a neutralizing antibody titer of ≥1:160, harvested by apheresis from patients recovering from H1N1 2009 infection. Clinical outcome was compared with that of patients who declined plasma treatment as the untreated controls. Results. Ninety-three patients with severe H1N1 2009 infection requiring intensive care were recruited. Twenty patients (21.5%) received plasma treatment. The treatment and control groups were matched by age, sex, and disease severity scores. Mortality in the treatment group was significantly lower than in the nontreatment group (20.0% vs 54.8%; P = .01). Multivariate analysis showed that plasma treatment reduced mortality (odds ratio OR, .20; 95% confidence interval CI, .06-.69; P = .011), whereas complication of acute renal failure was independently associated with death (OR, 3.79; 95% CI, 1.15-12.4; P = .028). Subgroup analysis of 44 patients with serial respiratory tract viral load and cytokine level demonstrated that plasma treatment was associated with significantly lower day 3, 5, and 7 viral load, compared with the control group (P < .05). The corresponding temporal levels of interleukin 6, interleukin 10, and tumor necrosis factor α (P < .05) were also lower in the treatment group. Conclusions. Treatment of severe H1N1 2009 infection with convalescent plasma reduced respiratory tract viral load, serum cytokine response, and mortality.
Background. Infections caused by the pandemic H1N1 2009 influenza virus range from mild upper respiratory tract syndromes to fatal diseases. However, studies comparing virological and immunological ...profile of different clinical severity are lacking. Methods. We conducted a retrospective cohort study of 74 patients with pandemic H1N1 infection, including 23 patients who either developed acute respiratory distress syndrome (ARDS) or died (ARDS-death group), 14 patients with desaturation requiring oxygen supplementation and who survived without ARDS (survived-without-ARDS group), and 37 patients with mild disease without desaturation (mild-disease group). We compared their pattern of clinical disease, viral load, and immunological profile. Results. Patients with severe disease were older, more likely to be obese or having underlying diseases, and had lower respiratory tract symptoms, especially dyspnea at presentation. The ARDS-death group had a slower decline in nasopharyngeal viral loads, had higher plasma levels of proinflammatory cytokines and chemokines, and were more likely to have bacterial coinfections (30.4%), myocarditis (21.7%), or viremia (13.0%) than patients in the survived-without-ARDS or the mild-disease groups. Reactive hemophagocytosis, thrombotic phenomena, lymphoid atrophy, diffuse alveolar damage, and multiorgan dysfunction similar to fatal avian influenza A H5N1 infection were found at postmortem examinations. Conclusions. The slower control of viral load and immunodysregulation in severe cases mandate the search for more effective antiviral and immunomodulatory regimens to stop the excessive cytokine activation resulting in ARDS and death.
There was a major outbreak of severe acute respiratory syndrome (SARS) affecting more than 300 patients occurring in a private housing estate in Hong Kong, in which an infected renal patient was ...suspected to be the primary source. It is unknown whether renal patients would represent a distinct group of patients who share some characteristics that could predispose them to have higher infectivity. In this context, we have encountered 4 dialysis patients contracting SARS in a minor outbreak, which involved 11 patients and 4 health care workers, in a medical ward of a regional hospital. Of these 4 dialysis patients, 1 patient was receiving hemodialysis while the other 3 patients were on continuous ambulatory peritoneal dialysis. Fever and radiological changes were their dominant presenting features. All were having positive results for SARS-associated coronavirus ribonucleic acid by reverse transcriptase-polymerase chain reaction performed on their nasopharyngeal aspirates or stool samples. It appeared that treatment with high-dose intravenous ribavirin and corticosteroids could only resolve the fever, but it could not stop the disease progression. All 4 patients developed respiratory failure requiring mechanical ventilation on days 9 through 12. At the end, all of the patients died from sudden cardiac arrest, which was associated with acute myocardial infarction in 2 cases. From this small case series, it appeared that dialysis patients might have an aggressive clinical course and poor outcome after contracting SARS. However, a large-scale study is required to further examine this issue, and further investigation into the immunologic abnormalities associated with the uremic state in this group of patients is also warranted.
Injudicious use of acetic acid can result in acute or chronic poisoning. Chronic ingestion of large amount of 5% acetic acid has been reported to be a cause for hypokalemia, hyper-reninemia and ...osteoporosis. Acute poisoning can occur after percutaneous treatment of hepatocellular carcinoma or after oral ingestion. Most of the reported cases are from Russia before 1980s. We report an adult with acute accidental poisoning with 30% acetic acid leading to severe intravascular hemolysis, hemoglobulinuria, acute hepatitis, coagulopathy, and acute gastrointestinal bleeding and acute renal failure. Plasmapheresis was started soon after intoxication with good recovery and we discuss its possible role in the management of acetic acid poisoning.
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