When Pigs Fly: Thromboembolic Events in a Case of Severe H1N1 Influenza Type A

Title: When Pigs Fly: Thromboembolic Events in a Case of Severe H1N1 Influenza Type A First Authors: Luna Liu, DO Co-Authors: Robyn Moran DO; Matthew Boehme, DO Attending: Donna Cota, DO; Mohan Sengodan, MD; Ranjit Nair, MD; Anupama Chennupati, MD; Background/Abstract: H1N1 Subtype Influenza Type A, the strain responsible for the 2009 pandemic, is primary regarded as a disease affecting lung parenchyma, yet it is its ability to infiltrate and cause system wide complications which has made it such a deadly virus1-2. It is hypothesize the disease process may cause a propensity for thromboembolic events through activation of platelets, alterations of coagulation factors, or endothelial dysfunction3. There have been multiple documented cases of pulmonary embolism and myocardial infarctions in prior reports in H1N1 infected individuals, but few of cerebral events4-6. We present a unique case of severe H1N1-influenza in a previously healthy 47 year old male whose hospital course was complicated by multiple cerebral infarcts and R-femoral DVT. Case Report: 47 year old caucasian male without a significant PMHx presented initially for fevers, myalgias, and respiratory distress requiring intubation at an outside facility. His condition worsened and was transferred to our facility for higher level of care. He was initially found to to have septic shock requiring pressor support and started on empiric antibiotics. On arrival, the pt also underwent a bronchoscopy with washings; multiple cultures of blood, bronchial washings, sputum were negative for any growth. The pt continue to have breakthrough fevers. On admission day 4, he was found to have a DVT of R-femoral vein and started on a heparin drip; of note, the pt had been on chemical DVT prophylaxis since admission. Pt had difficulty with arousability off sedation and underwent extensive work-up including CSF studies which were negative. An MRI was significant for multiple small bilateral cerebral infarcts. Repeat transthoracic echoes were negative for signs of endocarditis or PFO on bubble study. Pt improved following tracheostomy placement and was discharged to LTAC on day 17th of hospitalization. Discussion: This case serves to illustrate the widespread effects of Influenza Type A H1N1 Subtype, even in healthy individuals. In this particular case, the pt had both venous and arterial thromboembolic events which is unique. It is important to keep in mind the extent of the disease process in this disease, especially in critically-ill patients. References:
Dimitroulis, I. A., Katsaras, M., & Toumbis, M. (2016). H1N1 infection and embolic events: A multifaceted disease. Pneumon, 29(3), 230-235.
Coorevits, L., Demuynck, H., Boone, E., Roelens, J., & Surmont, I. (2011). Trombo-embolic complications in influenza A(H1N1)2009: A forgotten and fatal danger, also in so-called "mild" flu? [Trombo-embolische verwikkelingen bij influenza A(H1N1)2009: Een vergeten en fataal gevaar, ook bij "milde" griep?] Tijdschrift Voor Geneeskunde, 67(7), 337-339. 10.2143/TVG.67.07.2000941
Paul E. Bunce, Sasha M. High, Maral Nadjafi, Katherine Stanley, W. Conrad Liles, Michael D. Christian; Pandemic H1N1 Influenza Infection and Vascular Thrombosis, Clinical Infectious Diseases, Volume 52, Issue 2, 15 January 2011, Pages e14–e17, https://doi.org/10.1093/cid/ciq125
Avnon, L. S., Munteanu, D., Smoliakov, A., Jotkowitz, A., & Barski, L. (2015). Thromboembolic events in patients with severe pandemic influenza A/H1N1. Eur J Intern Med, 26(8), 596-598. doi:10.1016/j.ejim.2015.08.017
Chandra, M., & Chander, T. (2016). Uncommon presentation of H1N1-Bilateral pulmonary thrombo-embolism. J Assoc Physicians India, 64(1), 145.
Tsujii, N., Nogami, K., Yoshizawa, H., Hayakawa, M., Isonishi, A., Matsumoto, M., & Shima, M. (2016). Influenza-associated thrombotic microangiopathy with unbalanced von Willebrand factor and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 levels in a heterozygous protein S-deficient boy. Pediatr Int, 58(9), 926-929. doi:10.1111/ped.13014