Clinical analysis of the first maternal patient infected with novel avian Influenza A (H5N6) virus in the world

Abstract

Objective To report the treatment of the first maternal patient infected with novel avian Influenza A (H5N6) virus in the world, and to investigate the clinical features and treatment of the maternal patient. Methods On December 28th, 2015, a maternal patient infected with H5N6 virus was admitted to the First Municipal Hospital of Zhaoqing City. The clinical features and treatments of this patient were analyzed. Results ① A 40-year-old female in 35-week gestation was admitted with the complaint of fever and cough for 6 days with the following characteristics: fever 6 days ago after getting a cold, mainly in the afternoon and night, the maximum body temperature was 39 ℃, with chills, shiver, single cough, short of breath after walking 50 meters which could be relieved after having a rest, but no expectoration, sore throat, nasal obstruction, rhinorrhea, chest tightness, chest pain, paroxysmal nocturnal dyspnea. The body temperature could be decreased after taking antibiotic and antipyretic which was prescribed by the doctor in the local hospital, and was repeatedly administrated. ② She had been to the local live poultry market before the onset of fever. ③ Auxiliary examination: on admission, the patient's blood test showed that the white blood cell count was normal (7.94×109/L), the neutrophil was normal (7.42×109/L), but the lymphocyte was low (0.44×109/L); it was shown by the arterial blood gas analysis that pH was 7.441, the oxygen partial pressure was 68.7 mmHg (1 mmHg = 0.133 kPa), and the carbon dioxide partial pressure was 23.9 mmHg. Infiltration was found in the lung by chest X-ray on the 2nd day, specifically, with double lung texture thickening, fuzzy, visible patchy fuzzy shadow, and double lung portal shadow. On the 3rd day, the throat swab specimen and sputum for virus nucleic acid detection of H7N9-RNA was negative, the H1N1-RNA was negative, but the avian influenza virus (AIV)-RNA was positive. The throat swab specimens and sputum for virus nucleic acid detection were performed by Disease Prevention Control Center of Zhaoqing City on the 4th day and by Disease Prevention Control Center of Guangdong Province on the 5th day, which showed positive H5N6-RNA, but her child's nasal swab specimens for AIV-RNA was negative on the 3rd day of birth. On the 5th day, blood influenza A virus antibody IgM was negative. ④ Treatment: a medium flow oxygen inhalation by nasal cannula was given after admission. On the 2nd day, the breath of the patient raised to 40 breaths/min, and the pulse oxygen saturation (SpO2) fell to 0.80, in order to avoid the fetal death because of hypoxemia, the patient was send for cesarean section, and invasive ventilation was given with 1.00 fraction of inspired oxygen (FiO2) in the intensive care unit (ICU) after the cesarean section, and the extracorporeal membrane oxygenation (ECMO) was given since the 4th day. 150 mg oseltamivir was given bid on the 4th day for 2 times a day, and it was changed to peramivir 600 mg everyday (qd) on the 6th day for 6 days, and oseltamivir 150 mg was given bid again on the 9th day for 14 days. ⑤ Outcome: the throat appeared red, and the tonsils were swollen, breath sounds on both sides was weak, but no rale or rhonchi was found at admission. But from the 2nd day fine rales were detectable in both sides of chest. The temperature was normal except on the 1st day (the maximum body temperature was 38.2 ℃), the 4th day (the maximum body temperature was 38 ℃), and the 10th day (the maximum body temperature was 37.5 ℃). The viral nucleic acid test of the throat swab specimen and sputum showed that the H5N6-RNA turned negative on the 9th day, the 10th day and the 11th day for 3 days. Pleural effusion was rapidly increased after the admission as shown by chest X-ray films, bilateral partial ground-glass opacities were observed in the low lung, and extended to all the lung fields on the 5th day, the bilateral lung infiltrations were absorbed slowly, and showed bilateral reticular opacities as the image of pulmonary fibrosis at last. The computed tomography scan of the chest showed bilateral irregular reticular opacities and basal discoid atelectasis on the 31st day. The color Doppler ultrasonography showed the systolic pressure of the pulmonary artery was about 78 mmHg on the 39th day. On the 49th day, norepinephrine was given for the hypotension, the serum creatinine (SCr) was 73.9 μmol/L; the SCr raised to 160.2 μmol/L on the 50th day, the urine output fell to less than 30 mL/h for 27 hours. Although the active antiviral, mechanical ventilation, ECMO and other therapies were prescribed, the patient eventually died due to multiple organ failure (MOF) on the 50th day. Conclusions The reported patient course was short, with an acute onset, with fever and cough as the chief complaint, and acute respiratory distress syndrome (ARDS) and MOF developed quickly. Her baby was born through cesarean delivery on the 2nd day after admission, and had not infected with H5N6 avian influenza. The clinical manifestations and the treatment strategy need to be further explored. Key words: H5N6 avian influenza A;  Maternal;  Anti-viral drug;  Acute respiratory distress syndrome;  Extracorporeal membrane oxygenation