Dr. Akshay Kishore , Dr Sajith Kesavan (Paed pulmonologist and intensivist), Dr. Greeshma Issac Ped intensivist), Dr.C.Jayakumar, Amrita Institute of medical sciences.
Fifteen year old male child presented with complaints of fever , cough and fast breathing. for 3 days duration. This was associated with rhinitis and hemoptysis. Contact with viral illness was present . There was no petechiae , bruising or any other bleeding spots, vomiting or neck pain. His past medical history is unremarkable. Outside health care facility his saturation was low , increased work of breathing and X-ray showing bilateral alveolar opacities for which he was intubated.
On examination , child is intubated with FiO2 requirement of 70%. Initial labs showed CRP – 24.75 , TC – 4500 , N -25% , L – 70% with normal hemoglobin and platelets. INR – 0.90 with APTT – 32 and no transaminitis. Chest X-ray showed bilateral alveolar opacities. There was gradual fall in Hb and there was bloody aspirate with suctioning. Bronchoscopy was done which showed no bleeding from the airway upto subsegmental bronchi but there was progressively more hemorrhagic return from left lower lobe , lingula and right middle lobe suggestive of Diffuse alveolar haemorrhage (DAH).
ECHO was done which showed structurally normal heart and there was no evidence of any pulmonary hypertension. Autoimmune panel and vasculitis workup done was normal.
Respiratory viral panel was positive for influenza A virus.
Oseltamivir was added. Child got symptomatically better and bleeding decreased and he was extubated on Day 2 to room air and was discharged on Day 5.
Discussion : Influenza infection and its complication have caused significant increased mortality and morbidity worldwide. The clinical forms range from mild upper respiratory tract infection to encephalitis and ARDS. Influenza presenting and DAH is quite rare.
DAH may present with a course of variable severity and can lead to respiratory failure and death. Vasculitis being the most common etiology , infectious causes also should be ruled out.
Take home message- Influenza infection can be fatal and prompt intervention at the right time can save the child.
It is very prudent that all children should be vaccinated against influenza every year just before the onset of monsoon.