A Case of Suspicious A Case of Suspicious FEVERFEVER

Prof.Dr.P.Vijayaraghavan’s Prof.Dr.P.Vijayaraghavan’s UnitUnit

Dr.T.J.Senthil ManikandanDr.T.J.Senthil Manikandan

Saurav Das a 23 year old medical student Saurav Das a 23 year old medical student returning from Denmark after a stay of 4 returning from Denmark after a stay of 4 days [21days [21stst to 25 to 25thth April] was admitted for April] was admitted for fever of 12 daysfever of 12 days

HOPI:H/O fever-12 days HOPI:H/O fever-12 days - high grade- high grade - associated with chills &rigors- associated with chills &rigors - esp. in the evenings- esp. in the evenings No h/o headacheNo h/o headache No h/o altered sensoriumNo h/o altered sensorium No h/o visual disturbance/seizures/locNo h/o visual disturbance/seizures/loc

No h/o vomiting/diarrheaNo h/o vomiting/diarrhea h/o cough+h/o cough+ h/o sore throat+h/o sore throat+ h/o bodyache+h/o bodyache+ No h/o post nasal drip/running noseNo h/o post nasal drip/running nose No h/o jaundiceNo h/o jaundice No h/o chest pain/palpitation/syncopeNo h/o chest pain/palpitation/syncope No h/o pedal edema/abd.distensionNo h/o pedal edema/abd.distension No h/o oliguria/hematuriaNo h/o oliguria/hematuria No h/o dysuriaNo h/o dysuria No h/o bleeding tendancy/rash/joint painsNo h/o bleeding tendancy/rash/joint pains

So with h/o travel to a foreign country[confirmed So with h/o travel to a foreign country[confirmed flu cases reported] and fever with mild flu cases reported] and fever with mild respiratory symptoms the diagnosis of swine respiratory symptoms the diagnosis of swine flu was entertained.Throat &Nasal Swabs flu was entertained.Throat &Nasal Swabs were taken for viral studies.were taken for viral studies.

On further elaboration of history patient gave On further elaboration of history patient gave h/o fever starting on the day of his journey to h/o fever starting on the day of his journey to denmark; he had landed with fever there.denmark; he had landed with fever there.

Since there was h/o fever with rigors malaria Since there was h/o fever with rigors malaria also was considered as a possibility.also was considered as a possibility.

On questioning patient gave a past h/o On questioning patient gave a past h/o treatment for malaria 6 months back with treatment for malaria 6 months back with chloroquine and became alrightchloroquine and became alright

There was no other significant past history.There was no other significant past history.

Personal History:Personal History:

Non smoker,non alcoholicNon smoker,non alcoholic

Mixed dietMixed diet

Family history:Family history:

No other member has a similar illness.His No other member has a similar illness.His Father is a diabeticFather is a diabetic

O/E:O/E:

Patient conscious,oriented,afebrilePatient conscious,oriented,afebrile

Not pale,anictericNot pale,anicteric

No cyanosis,no clubbingNo cyanosis,no clubbing

JVPJVPº,PEº,LNº º,PEº,LNº

no external markers of TB,no rashno external markers of TB,no rash

BP-130/90mmHg,PR-90/m,RR-16/mBP-130/90mmHg,PR-90/m,RR-16/m

HT- 175 cms,WT-80 kgs,WC-36"HT- 175 cms,WT-80 kgs,WC-36"

CVS- S1,S2 +CVS- S1,S2 +

no murmursno murmurs

RS- BAE+,NVBSRS- BAE+,NVBS

No added soundsNo added sounds

P/A- soft P/A- soft

spleen was just palpablespleen was just palpable

CNS-NFND CNS-NFND

No neck stiffnessNo neck stiffness

Investigations Investigations Hb -11.6gms%Hb -11.6gms%PCV-39%PCV-39%TC -6400/cmmTC -6400/cmmDC- P66 L30 E2 M2DC- P66 L30 E2 M2

ESR-21/45ESR-21/45RBS-116 mgs/dlRBS-116 mgs/dlBld urea-22 mgs/dlBld urea-22 mgs/dlSr creatinine-0.7 mgs/dlSr creatinine-0.7 mgs/dlsr electrolytes Na-137,K-4.9meq/lsr electrolytes Na-137,K-4.9meq/l Cl-102,HCO3-24 meq/lCl-102,HCO3-24 meq/l

Platelet Platelet countcount

Day 1Day 1 Day 2Day 2 Day 4Day 4 Day 7Day 7

5100051000 6500065000 8700087000 160000160000

Sr bilirubin-3.2mgs/dlSr bilirubin-3.2mgs/dlDirect-1.9 mgs/dlDirect-1.9 mgs/dlSGOT-36 u/lSGOT-36 u/lSGPT-41u/lSGPT-41u/lALP-161 Iu/lALP-161 Iu/lTotal protein-6.3 gms%,sr albumin-2.6 gms%Total protein-6.3 gms%,sr albumin-2.6 gms%PT-14 s,INR-1,aPTT-26sPT-14 s,INR-1,aPTT-26sECG-sinus tachycardiaECG-sinus tachycardiaCXR-PA-WNLCXR-PA-WNLUrine R/E-alb,sugar-nilUrine R/E-alb,sugar-nil 1-2 pus cells1-2 pus cells

QBC-MP-+VeQBC-MP-+Ve

Peripheral smear-p.vivax+Peripheral smear-p.vivax+

MSAT- -veMSAT- -ve

Widal- -veWidal- -ve

Dengue IGM- -veDengue IGM- -ve

Nasal and throat swab for HINI Nasal and throat swab for HINI virus-negativevirus-negative

USG abdomen-focal sparing in fatty USG abdomen-focal sparing in fatty liver,splenomegaly -suggested follow up liver,splenomegaly -suggested follow up with CT or MRI[MGE OPINION]with CT or MRI[MGE OPINION]

ELISA for HIV- -veELISA for HIV- -ve HBsAg- -veHBsAg- -ve Anti-HCV- -veAnti-HCV- -ve Blood C&S- -veBlood C&S- -ve Urine C&S- -veUrine C&S- -ve Lipid profile Lipid profile tot cholesterol-220,LDL-135tot cholesterol-220,LDL-135 HDL-38,TGL-284 mgs%HDL-38,TGL-284 mgs% FBS-71 mgs%FBS-71 mgs% PPBS-203 mgs%PPBS-203 mgs%

FINAL DIAGNOSISFINAL DIAGNOSIS MALARIA[P.VIVAX]MALARIA[P.VIVAX] METABOLIC SYNDROMEMETABOLIC SYNDROME→DM→DM

TREATMENTTREATMENT Because of initial consideration of swine Because of initial consideration of swine

flu 1 dose of TAMIFLU was givenflu 1 dose of TAMIFLU was given On getting the peripheral smear report On getting the peripheral smear report T chloroquine was started and full course T chloroquine was started and full course was given-since fever persistedwas given-since fever persisted Inj Artesunate was given in the usual Inj Artesunate was given in the usual

dose.Fever subsideddose.Fever subsidedRadical treatment with T primaquine was Radical treatment with T primaquine was

givengiven

He was asked to come for followup to He was asked to come for followup to work the case up regarding diabetic work the case up regarding diabetic status, metabolic syndrome,fatty liver and status, metabolic syndrome,fatty liver and abnormal LFTabnormal LFT

This case is being presented since on This case is being presented since on admission there was a clinical suspicion of admission there was a clinical suspicion of swine flu.swine flu.

But lab investigations were not in favour of But lab investigations were not in favour of this diagnosis and suggested a relapse of this diagnosis and suggested a relapse of malarial fever because radical treatment malarial fever because radical treatment was not given during the first episode 6 was not given during the first episode 6 months back.months back.

SWINE FLU –THE NEW H1N1SWINE FLU –THE NEW H1N1

HINI VIRUSHINI VIRUS

The Influenza Pandemic of 1918 The Influenza Pandemic of 1918 Known as "Spanish Flu" or "La Grippe" Known as "Spanish Flu" or "La Grippe" It killed more people than the World War I It killed more people than the World War I

> 20 to 40 million people. > 20 to 40 million people. It has been cited as the most devastating It has been cited as the most devastating

epidemic in recorded world history. More epidemic in recorded world history. More people died of influenza in a single year people died of influenza in a single year than in four-years of the Black Death than in four-years of the Black Death Bubonic Plague from 1347 to 1351.Bubonic Plague from 1347 to 1351.

It was caused by H1N1 It was caused by H1N1

H1N1-Swine fluH1N1-Swine flu The The 2009 outbreak of Influenza A virus 2009 outbreak of Influenza A virus

subtype H1N1subtype H1N1is an epidemic of a new strain of is an epidemic of a new strain of influenza virus commonly referred to as swine influenza virus commonly referred to as swine flu. flu.

It is thought to be a mutation (reassortment) of It is thought to be a mutation (reassortment) of four known strains of influenza A virus subtype four known strains of influenza A virus subtype H1N1: one endemic in humans, one endemic in H1N1: one endemic in humans, one endemic in birds, and two endemic in pigs (swine). birds, and two endemic in pigs (swine).

The WHO&CDC have raised its alert level to The WHO&CDC have raised its alert level to Phase 5 out of the six maximum, indicating that Phase 5 out of the six maximum, indicating that a pandemic was "imminent".a pandemic was "imminent".

outbreakoutbreak→PANDEMIC?→PANDEMIC?

Travel advisoriesTravel advisories The new strain has spread widely beyond The new strain has spread widely beyond

Mexico and the U.S., with confirmed cases Mexico and the U.S., with confirmed cases in >50 countries in >50 countries

To avoid travelling to infected areas, To avoid travelling to infected areas, especially Mexico & USA especially Mexico & USA

VirulenceVirulence Most fatalities have been in Mexico (87%, Most fatalities have been in Mexico (87%,

as of May 24, 2009) primarily young, as of May 24, 2009) primarily young, healthy adultshealthy adults

Symptoms and expected severitySymptoms and expected severity They are similar to usual influenza, and include a fever, They are similar to usual influenza, and include a fever,

coughing, headaches, pain in the muscles or joints, sore coughing, headaches, pain in the muscles or joints, sore throat, chills, fatigue and runny nosethroat, chills, fatigue and runny nose

Diarrhea and vomiting have also been reported in some Diarrhea and vomiting have also been reported in some cases. cases.

People at higher risk of serious complications include People at higher risk of serious complications include 1.people age 65 years and older 1.people age 65 years and older 2.children younger than 5 years old 2.children younger than 5 years old 3.pregnant women 3.pregnant women 4.people of any age with underlying medical 4.people of any age with underlying medical

conditions such as asthma, diabetes, obesity, conditions such as asthma, diabetes, obesity,

heart disease, or immunocompromised ppheart disease, or immunocompromised pp

Emergency medical attentionEmergency medical attention In children, look for blue lips and skin, In children, look for blue lips and skin,

dehydration, rapid breathing, excessive dehydration, rapid breathing, excessive sleeping and significant irritability that sleeping and significant irritability that includes a lack of desire to be held. includes a lack of desire to be held.

In adults, shortness of breath, pain in the In adults, shortness of breath, pain in the chest or abdomen, sudden dizziness or chest or abdomen, sudden dizziness or confusion may indicate the need for confusion may indicate the need for emergency care. emergency care.

PreventionPrevention Personal hygiene and surgical masksPersonal hygiene and surgical masksTreatmentTreatment The drugs that are used for treating H1N1 The drugs that are used for treating H1N1

flu are called oseltamivir (Tamiflu) and flu are called oseltamivir (Tamiflu) and zanamivir (Relenza).zanamivir (Relenza).

The drugs work best if given within 2 days The drugs work best if given within 2 days of becoming ill, but may be given later if of becoming ill, but may be given later if illness is severe or for those at a high risk illness is severe or for those at a high risk for complications. for complications.

The CDC case definitions The CDC case definitions Confirmed case:Confirmed case: A person with an acute A person with an acute

febrile respiratory illness with lab febrile respiratory illness with lab confirmed infection at the CDC by one or confirmed infection at the CDC by one or more of the following tests: more of the following tests: Real-time reverse-transcription Real-time reverse-transcription

polymerase chain reaction (RT-PCR) polymerase chain reaction (RT-PCR) Viral culture Viral culture

Probable case:Probable case: A person with ILI (ie, an A person with ILI (ie, an illness with a fever and a cough or sore illness with a fever and a cough or sore throat) who is positive for influenza A, but throat) who is positive for influenza A, but negative for H1 and H3 by RT-PCR. negative for H1 and H3 by RT-PCR.

Suspected case:Suspected case: A person who does not meet the A person who does not meet the confirmed or probable case definition, is not novel H1N1 confirmed or probable case definition, is not novel H1N1 test–negative, and is/has one of the following features: test–negative, and is/has one of the following features: Previously healthy, less than 65 years of age, and Previously healthy, less than 65 years of age, and

hospitalized for ILI hospitalized for ILI ILI and resides in a state without confirmed cases but ILI and resides in a state without confirmed cases but

has traveled to a state or country where there is/are has traveled to a state or country where there is/are one or more confirmed or probable cases one or more confirmed or probable cases

ILI and has an epidemiologic link in the past 7 days to ILI and has an epidemiologic link in the past 7 days to a confirmed case or probable casea confirmed case or probable case

Antiviral treatment should be considered for confirmed, Antiviral treatment should be considered for confirmed, probable and suspected cases of novel H1N1 infection, probable and suspected cases of novel H1N1 infection, with priority given to hospitalized patients and patients at with priority given to hospitalized patients and patients at higher risk for influenza complicationshigher risk for influenza complications

Treatment & ChemoprophylaxisTreatment & ChemoprophylaxisOseltamivirOseltamivir Adults & children ≥ 13 yrsAdults & children ≥ 13 yrs 75 mg capsule twice per day for 5 days,75 mg capsule 75 mg capsule twice per day for 5 days,75 mg capsule

once per day for 10 days after last known exposureonce per day for 10 days after last known exposure Children (12 months to 12 yrs) Children (12 months to 12 yrs) ≤ ≤ 15 kg-30 mg twice daily for 5 days,30 mg once daily for 15 kg-30 mg twice daily for 5 days,30 mg once daily for

10 days after last known exposure10 days after last known exposure 15-23 kg-45 mg twice daily for 5 days,45 mg once daily 15-23 kg-45 mg twice daily for 5 days,45 mg once daily

for 10 days after last exposurefor 10 days after last exposure 24-40 kg-60 mg twice daily for 5 days,60 mg once daily 24-40 kg-60 mg twice daily for 5 days,60 mg once daily

for 10 days after last exposurefor 10 days after last exposure > 40 kg-75 mg twice daily for 5 days,75 mg once daily for > 40 kg-75 mg twice daily for 5 days,75 mg once daily for

10 days after last exposure10 days after last exposure

ZanamivirAdultsZanamivirAdults Two 5 mg inhalations (10mg total) twice per day Two 5 mg inhalations (10mg total) twice per day

for 5 days for 5 days prophylaxisprophylaxis Two 5 mg inhalations (10mg total) once per day Two 5 mg inhalations (10mg total) once per day

for 10 days after last known exposurefor 10 days after last known exposure ChildrenTwo 5 mg inhalations (10mg total) twice ChildrenTwo 5 mg inhalations (10mg total) twice

per day (age 5 yrs or older) for 5 daysper day (age 5 yrs or older) for 5 daysprophylaxisprophylaxis Two 5 mg inhalations (10mg total) once per day Two 5 mg inhalations (10mg total) once per day

(age 5 yrs or older) for 10 days after last (age 5 yrs or older) for 10 days after last exposure exposure

VaccinesVaccines The seasonal flu vaccine is not believed to protect The seasonal flu vaccine is not believed to protect

against the new strain, therefore any existing stock against the new strain, therefore any existing stock would not be useful.would not be useful.

Quarantine-incubation period[1-7 days]Quarantine-incubation period[1-7 days] It is for at least 7 days after last exposure or until we are It is for at least 7 days after last exposure or until we are

sure that the person has not been exposed to the virus.sure that the person has not been exposed to the virus. If he/she develop signs or symptoms of swine flu then If he/she develop signs or symptoms of swine flu then

quarantine for up to 7 days from the start of symptoms.quarantine for up to 7 days from the start of symptoms. Persons who continue to be ill longer than 7 days after illness Persons who continue to be ill longer than 7 days after illness

onset should be considered potentially contagious until onset should be considered potentially contagious until symptoms have resolved. symptoms have resolved.

Children (especially younger children) and immunosuppressed Children (especially younger children) and immunosuppressed or immunocompromised persons might be contagious for longer or immunocompromised persons might be contagious for longer periodsperiods

DANGERS-WHAT&WHYDANGERS-WHAT&WHY The secondary attack rate of H1N1 range from The secondary attack rate of H1N1 range from

22% to 33%. The secondary attack rate of 22% to 33%. The secondary attack rate of seasonal influenza ranges from 5% to 15%. seasonal influenza ranges from 5% to 15%.

A younger age-group has been affected than A younger age-group has been affected than seen during seasonal epidemics of influenza. seen during seasonal epidemics of influenza. Although cases have been confirmed in all age-Although cases have been confirmed in all age-groups, the youth of patients with severe or groups, the youth of patients with severe or lethal infections is a striking feature of early lethal infections is a striking feature of early outbreaks. outbreaks.

The tendency of the H1N1 virus to cause more The tendency of the H1N1 virus to cause more severe and lethal infections in people with severe and lethal infections in people with underlying conditions is of particular concern. underlying conditions is of particular concern.

The full clinical spectrum of disease caused by The full clinical spectrum of disease caused by H1N1 will not become apparent until the virus is H1N1 will not become apparent until the virus is more widespread. more widespread.

The intrinsic mutability of influenza viruses could The intrinsic mutability of influenza viruses could alter the severity of current disease patterns, if alter the severity of current disease patterns, if the virus continues to spread. the virus continues to spread.

Possible changes that could take place as the Possible changes that could take place as the virus spreads to the southern hemisphere and virus spreads to the southern hemisphere and encounters currently circulating human viruses . encounters currently circulating human viruses .

H5N1 avian influenza virus is firmly established H5N1 avian influenza virus is firmly established in poultry in some parts of the world is another in poultry in some parts of the world is another cause for concern. No one can predict how the cause for concern. No one can predict how the H5N1 virus will behave under the pressure of a H5N1 virus will behave under the pressure of a pandemic. pandemic.

Pigs have been considered a "mixing vessel“, Pigs have been considered a "mixing vessel“, they can be infected with influenza A viruses they can be infected with influenza A viruses from avian, human, or swine originfrom avian, human, or swine origin

The 1918 pandemic began with a relatively The 1918 pandemic began with a relatively mild "herald" wave in the spring of 1918,but mild "herald" wave in the spring of 1918,but the damage the subsequent peaks caused is the damage the subsequent peaks caused is well known. well known.

The FAO& WHO have reaffirmed that the H1N1 The FAO& WHO have reaffirmed that the H1N1 virus is not known to be transmissible from virus is not known to be transmissible from eating cooked pork or pork products.eating cooked pork or pork products.

CDC was reporting >10000 U.S. cases in 50 CDC was reporting >10000 U.S. cases in 50 states resulting in fourteen deaths, but noted states resulting in fourteen deaths, but noted that for the most part, the infections continue to that for the most part, the infections continue to be mild—similar to seasonal flu—and recovery is be mild—similar to seasonal flu—and recovery is fairly quickfairly quick

Several of the proteins of the virus are most Several of the proteins of the virus are most similar to strains that cause mild symptoms in similar to strains that cause mild symptoms in humans.humans.

Drugs until now have been reasonably effectiveDrugs until now have been reasonably effective

THANK YOUTHANK YOU

H1N1H1N1 caused " caused "Spanish FluSpanish Flu" and the " and the 2009 swine flu outbreak2009 swine flu outbreak

H2N2H2N2 caused "Asian Flu" caused "Asian Flu" H3N2H3N2 caused "Hong Kong Flu" caused "Hong Kong Flu" H5N1H5N1 is "bird flu", endemic in avians is "bird flu", endemic in avians H7N7H7N7 has unusual has unusual zoonoticzoonotic potential potential H1N2H1N2 is currently endemic in humans and is currently endemic in humans and

pigspigs

Name of pandemicDateDeathsSubtype Name of pandemicDateDeathsSubtype involvedinvolved

Asiatic (Russian) FluAsiatic (Russian) Flu1889–90 1889–90 1 million 1 million H2N2H2N2 Spanish FluSpanish Flu 1918–201918–20 40 million 40 million H1N1H1N1 Asian FluAsian Flu 1957–58 1957–58 1 to 1.5 million 1 to 1.5 million H2N2H2N2 Hong Kong FluHong Kong Flu 1968–691968–69 0.75 to 1 million0.75 to 1 millionH3N2H3N2

Influenza A virus subtype H5N1, also known as A(H5N1) or simply H5N1, is Influenza A virus subtype H5N1, also known as A(H5N1) or simply H5N1, is a subtype of the a subtype of the Influenza A virusInfluenza A virus which can cause illness in humans and which can cause illness in humans and many other animal species.many other animal species.[43][43] A bird-adapted strain of H5N1, called HPAI A bird-adapted strain of H5N1, called HPAI A(H5N1) for "highly A(H5N1) for "highly pathogenicpathogenic avian influenza virus of type A of subtype avian influenza virus of type A of subtype H5N1", is the causative agent of H5N1", is the causative agent of H5N1 fluH5N1 flu, commonly known as ", commonly known as "avian influenzaavian influenza" or "bird flu". It is " or "bird flu". It is endemicendemic in many bird populations, in many bird populations, especially in especially in Southeast AsiaSoutheast Asia. .

One strain of HPAI A(H5N1) is spreading globally after first appearing in One strain of HPAI A(H5N1) is spreading globally after first appearing in Asia. It is epizootic (an epidemic in nonhumans) and panzootic (affecting Asia. It is epizootic (an epidemic in nonhumans) and panzootic (affecting animals of many species, especially over a wide area), killing tens of animals of many species, especially over a wide area), killing tens of millions of birds and spurring the culling of hundreds of millions of others to millions of birds and spurring the culling of hundreds of millions of others to stem its spread. Most mentions of "bird flu" and H5N1 in the media refer to stem its spread. Most mentions of "bird flu" and H5N1 in the media refer to this strain.this strain.

HPAI A(H5N1) is an avian disease. There is no evidence of efficient human-HPAI A(H5N1) is an avian disease. There is no evidence of efficient human-to-human transmission or of airborne transmission of HPAI A(H5N1) to to-human transmission or of airborne transmission of HPAI A(H5N1) to humans. In almost all cases, those infected with H5N1 had extensive humans. In almost all cases, those infected with H5N1 had extensive physical contact with infected birds. Still, around 60% of humans known to physical contact with infected birds. Still, around 60% of humans known to have been infected with the current Asian strain of HPAI A(H5N1) have died have been infected with the current Asian strain of HPAI A(H5N1) have died from it, and H5N1 may mutate or reassort into a strain capable of efficient from it, and H5N1 may mutate or reassort into a strain capable of efficient human-to-human transmission.[45][46][human-to-human transmission.[45][46][