Virus-associated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection

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Virus-associated hemophagocytic syndrome (VAHS) is a severe complication of various viral infections often resulting in multiorgan failure and death. The purpose of this study was to describe baseline characteristics, development of VAHS, related treatments and associated mortality rate of consecutive critically ill patients with confirmed 2009 influenza A (H1N1) infection and respiratory failure. Methods We conducted a prospective observational study of 25 critically ill patients with 2009 influenza A (H1N1) infection at a single-center intensive care unit in Germany between 5 October 2009 and 4 January 2010. Demographic data, comorbidities, diagnosis of VAHS, illness progression, treatments and survival data were collected. The primary outcome measure was the development of VAHS and related mortality. Secondary outcome variables included duration of mechanical ventilation, support of extracorporeal membrane oxygenation and duration of viral shedding. Results VAHS developed in 9 (36%) of 25 critically ill patients with confirmed 2009 influenza A (H1N1) infection, and 8 (89%) of them died. In contrast, the mortality rate in the remaining 16 patients without VAHS was 25% ( P = 0.004 for the survival difference in patients with or without VAHS by log-rank analysis). The patients were relatively young (median age, 45 years; interquartile range (IQR), 35 to 56 years of age); however, 18 patients (72%) presented with one or more risk factors for a severe course of illness. All 25 patients received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia, with a median duration of mechanical ventilation of 19 days (IQR, 13 to 26 days). An additional 17 patients (68%) required extracorporeal membrane oxygenation for a median of 10 days (IQR, 6 to 19 days). Conclusions The findings of this study raise the possibility that VAHS may be a frequent complication of severe 2009 influenza A (H1N1) infection and represents an important contributor to multiorgan failure and death.

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Published 01 January 2011
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Beutelet al.Critical Care2011,15:R80 http://ccforum.com/content/15/2/R80
R E S E A R C HOpen Access Virusassociated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection 1* 21 34 3 Gernot Beutel, Olaf Wiesner , Matthias Eder , Carsten Hafer , Andrea S Schneider , Jan T Kielstein , 5 66 75 8 Christian Kühn , Albert Heim , Tina Ganzenmüller , HansHeinrich Kreipe , Axel Haverich , Andreas Tecklenburg , 1 22 Arnold Ganser , Tobias Welteand Marius M Hoeper
Abstract Introduction:Virusassociated hemophagocytic syndrome (VAHS) is a severe complication of various viral infections often resulting in multiorgan failure and death. The purpose of this study was to describe baseline characteristics, development of VAHS, related treatments and associated mortality rate of consecutive critically ill patients with confirmed 2009 influenza A (H1N1) infection and respiratory failure. Methods:We conducted a prospective observational study of 25 critically ill patients with 2009 influenza A (H1N1) infection at a singlecenter intensive care unit in Germany between 5 October 2009 and 4 January 2010. Demographic data, comorbidities, diagnosis of VAHS, illness progression, treatments and survival data were collected. The primary outcome measure was the development of VAHS and related mortality. Secondary outcome variables included duration of mechanical ventilation, support of extracorporeal membrane oxygenation and duration of viral shedding. Results:VAHS developed in 9 (36%) of 25 critically ill patients with confirmed 2009 influenza A (H1N1) infection, and 8 (89%) of them died. In contrast, the mortality rate in the remaining 16 patients without VAHS was 25% (P= 0.004 for the survival difference in patients with or without VAHS by logrank analysis). The patients were relatively young (median age, 45 years; interquartile range (IQR), 35 to 56 years of age); however, 18 patients (72%) presented with one or more risk factors for a severe course of illness. All 25 patients received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia, with a median duration of mechanical ventilation of 19 days (IQR, 13 to 26 days). An additional 17 patients (68%) required extracorporeal membrane oxygenation for a median of 10 days (IQR, 6 to 19 days). Conclusions:The findings of this study raise the possibility that VAHS may be a frequent complication of severe 2009 influenza A (H1N1) infection and represents an important contributor to multiorgan failure and death.
Introduction In the spring of 2009, novel human influenza A (H1N1) (A/H1N1/2009) infection began spreading from Mexico around the globe, causing a worldwide pandemic [13]. Contrary to initial fears, most patients experienced a mild clinical course. Some patients did become critically ill with respiratory failure, however, requiring intensive
* Correspondence: Beutel.Gernot@mhhannover.de 1 Departments of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, CarlNeubergStrasse 1, D30625 Hannover, Germany Full list of author information is available at the end of the article
care and ventilator support. Mortality rates were high in these patients, especially in those who developed multi organ failure [46]. The mechanisms leading to multiorgan failure and death in patients with influenza infection are not well understood. Septicemia is a leading cause of seasonal influenza, mainly due to secondary infection by other microorganisms, principally Grampositive or Gram negative bacteria. The first reports of fatal A/H1N1/ 2009 infections, however, only described septicemia occasionally [7,8]. Other pathomechanisms may also
© 2011 Beutel et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.