58-year-old man, ambulance driver, with a history of active smoking (5 cigarettes/day) and obesity (BMI 31 kg/m2) and 5 days history of myalgia, cough and rhinorrhea.
One day before admission dyspnea and quantitative compromise of consciousness were added.
The patient was admitted to the emergency department with compromised consciousness, poorly perfused, hypotensive (106/46 mmHg), tachycardic (106/min), with the use of accessory musculature in both lung fields oxyhemoglobin 67%.
Therapy was administered with high-flow mask without response, so the patient was admitted to the ICU.
Laboratory tests showed impaired renal function with plasma creatinine of 2.45 mg/dL since admission and NU of 47 mg/dL.
She had high CRP (200 mg/L), with normal leukocytes, erythrocytes and platelet counts.
In addition, she had elevated plasma LDH (1,500 U/L) and arterial lactate 45 mg/dL (4.5-14.4).
The chest X-ray confirmed a multilobar pneumonia so empirical treatment with ceftriaxone, moxifloxacin and oseltamivir was initiated.
1.
The patient was admitted with shock (with noradrenaline requirements up to 0.15 μg/kg/min) and catastrophic respiratory failure on mechanical ventilation (MV).
Microbiological study showed no agents by hemocultives, urocultives, culture of endotracheal aspirate or viral panel by immunofluorescence.
HIV serology was negative and influenza A H1N1 pdm09 was confirmed by PCR.
The PCR study also revealed the presence of ADV and RSV in the airway.
Noradrenaline requirements decreased from 48 h after admission (0.03 μg/kg/min), respiratory failure (PaFi > 250), so the patient returned to supine position.
However, AKI progressed from oliguria to anuria, with increased creatinine to 5.7 mg/dL, NU to 98 mg/dL and severe hyperkalemia.
Dialysis support was started with daily intermittent HD.
The evolution of oliguria to anuria did not allow the performance of EF; however, the patient had been resuscitated and stabilized (with minimal hemodynamic-adrenal requirement), which was not a pre-renal component.
Abdominal images could not be performed to evaluate the renal anatomy since its condition prevented its realization.
The patient had a new blood gas deterioration with PaFi less than 150, which made it necessary to return to MV in prone position.
Ventricular failure was ruled out by echocardiography and 62.5 mg methylprednisolone boluses were administered for 5 days in the context of severe ARDS.
The urine test, when recovering from diuresis, showed an inflammatory profile with proteinuria of 300 mg/dL, hematuria with irregular erythrocytes and proteinuria/creatinine index of 7.384 mg/g.
CK, C3 and C4 values were normal and the autoimmune study with ANCA-c, ANCA-p and ANA was negative.
The study of viral markers of hepatitis B and C was negative.
The patient progressively improved his respiratory condition and stopped at 21 days.
In total, 15 HD sessions were completed recovering renal function, with improvement of inflammatory urinary sediment (proteinuria 30 mg/dL and erythrocytes 2-4 per field) and normalization of diuresis.
She was discharged after one and a half month of hospitalization.
The patient had an indication of influenza vaccine due to obesity and being a health care professional, but had not received it.
A follow-up one year later showed normal renal function and normal urine sediment.
Molecular studies
In the Instituto de Salud Pública de la República of Nucleic Acids in Bogotá, Colombia, respiratory samples were extracted from the EASYMAG kit for total viral diseases in Chile.
RT-RPC was performed using the CDC standard protocol for respiratory detection and subtyping of influenza viruses (CDC real time RT-PCR protocol for detection and characterization of influenza knowledge, 2012) and for other respiratory viruses (Recltime RT-PCR).
A panel of respiratory viruses was amplified, including influenza, respiratory viruses described previously without metapneumovirus, definite origin 1, 2 and 3, adenovirus and rhinovirus, which allowed the detection of coinfection.
In addition, in order to explore the existence of mutations that could be potentially associated with greater clinical severity, we performed a sequencing study of the HA1 segment of viral haemagglutinin, by means of the Aped Biosystem sequencing.
Both samples were compared with a group of 76 samples from different regions of the country, both outpatients and inpatients, including 11 samples of deceased patients.
The analysis of the sequencing of the HA1 segment of influenza H1N1pdm09 virus, compared with the standard strain A/California/07/2009, showed that both cases presented the same eight mutations analyzed 2015).
However, the sample of case 1 showed in a single form the D222N mutation that was not detected in any of the other samples analyzed.
In the two samples analyzed and in the rest of the samples of this season, no other mutations previously reported as A90S or K180Q were detected.
