H1N1 pneumonitis treated with intravenous zanamivir

摘要: On July 8, 2009, a 22-year-old woman, neutropenic after chemotherapy for Hodgkin’s disease, was referred to ICU with 3 days’ (d) increasing dyspnoea, bilateral chest in fi ltrates, and laboratory-confi rmed pandemic H1N1 2009 infl uenza virus infection not responding oseltamivir 75 mg twice daily broad-spectrum antimicrobials (mero penem, teicoplanin, caspofungin). No other organisms were detected from blood or respiratory tract. Deterioration necessitated invasive ventilation d (fi gure). She remained single organ failure requiring high inspired oxygen, protective lung (tidal volumes ≤6–8 mL/kg), neutral fl uid balance. Hydro cortisone given (d 3–6), then gradually reduced discontinued 13). Neutropenia recovered by 6, although lymphopenia (webappendix). High level RNA bronchoalveolar lavage (BAL) on 10, despite 6 nasogastrically; view of volume gastric aspirates, this replaced nebulised zanamivir 6–13). Treatment escalation 13–16 delivered neither clinical nor virological response 16, intravenous 600 (provided GlaxoSmithKline, Brentford, Middlesex) started as unlicensed antiviral monotherapy; agreement use granted the Hospital Formulary Committee next kin. Methylprednisolone also started. Our patient’s condition improved within 48 h, decrease BAL viral load 21. extubated 21 discharged ward 24. Antiviral steroid treatment stopped 26 28, respectively. Since discharge she remains stable. Of four nasopharyngeal swabs taken post-ICU, third, 10 showed Ct 24, repeat sample day negative. In her immunosuppressed state ongoing lymphopenia, inhaled precaution, status unchanged. Deaths due are primarily related severe failure. patient did respond exten sive 2 weeks’ mechanical ventilation. RT-PCR detects rather than infectious virus, but is used semi-quantitatively assess replication. The small diff erence between 16 implied continued high-level Eff ective treat ment depends adequate enteral absorption (oseltamivir) an uninhibited access infected respira tory tissue (zanamivir). we zanamivir. amed, atelectatic lungs probably im peding drug absorption, improve forth coming, (un licensed) dosing achieves eff epithelial concentrations well-tolerated. pa tient no side-eff ects. Despite herent sampling inconsistencies, change 23 30 5 indicates approximate 128-fold fall load. Persisting replication may drive ammation brosis (im plied our poor compliance). We reasoned that synergism could exist intra venous high-dose corticosteroids, al though approach be considered controversial recom mended guide lines. However, con trolled trials lacking rationale does corticosteroids ARDS. Although case report direct cause ect cannot confi rmed, prove following encourages prompt further investigation, both alone com bination methyl pred nisolone.