Chinese doctors publish first H7N9 case report

Apr 10, 2013 (CIDRAP News) – Doctors from China today published the first case report of a patient infected with the H7N9 avian influenza virus, a 52-year-old woman from Shanghai who was admitted to the hospital late in her illness and died without having received antiviral treatment.

The team from Fudan University's Huashan Hospital, where the woman was seen in the emergency department, was hospitalized, and died, described their findings today in an online edition of Emerging Microbes and Infections. The woman's death was first reported on Apr 4.

She experienced a sudden onset of chills and fever on Mar 27 and was seen in the emergency department the next day. The patient had rough breath sounds and was given antibiotics.

A few days later she sought care at the facility again, at which point she still had a fever but no cough or shortness of breath. Radiographs showed small patchy shadows in the lower lobe of her right lung, and doctors treated her with intravenous antibiotics for 3 days.

Her condition quickly worsened, and she went to the emergency department again, this time with respiratory symptoms, including shortness of breath. After tests showed hypoxia and computed tomography demonstrated evidence of pneumonia, the woman's medical team suspected severe flu with respiratory distress, intubated the patient, and placed her on mechanical ventilation.

Despite those measures and treatment with methylprednisolone, antibiotics, and immune globulin treatment, her condition continued to deteriorate and she died on Apr 3. Doctors sent respiratory sampled to the Chinese Center for Disease Control, where tests detected the H7N9 virus.

An investigation into the source of her infection found no clear history of contact with livestock or poultry, through the virus was detected in poultry at a local market. "The most likely source of the virus in this case seems to be from the environment or food contaminated with this novel virus," the group wrote.

Close contact monitoring found that her husband had a fever, but tests on his samples were negative and he has recovered, according to the report. The group said animal-to-human transmission and human-to-human transmission are both being considered in her case.

The group noted that the proportion of fatal cases in H7N9 infections so far appears to be lower than for H5N1 infections. However, they noted that patients with fatal cases in Shanghai so far were admitted to the hospital very late with shortness of breath, with subsequent late treatment and a poor outcome, similar to the H5N1 experience.

Because the cause of illness was unclear, she and other H7N9 patients did not receive early antiviral treatment, which if given earlier coupled with earlier hospitalization might have significantly improved the woman's chances of surviving the H7N9 infection.

In a related commentary in the same issue, the Yu-Mei Wen, MD, a virologist from the same university, and Hans-Dieter Klenk, MD, a virologist from the University of Marburg in Germany, addressed the clinical patterns seen in some of the early H7N9 cases. Wen and Klenk are editors-in-chief of Emerging Microbes and Infections.

They noted that in Shanghai's first two cases, an 87-year-old man and a 27-year-old man who died, the patients had fever and respiratory symptoms early in their illness, which progressed to pneumonia and breathing problems 5 to 10 days later.

The two men had contact with pigs but not poultry, while other case-patients had a history of slaughtering chickens, they observed.

Many questions still remain about the animal reservoir and whether the human H7N9 infections are rare or represent the tip of the asymptomatic infection iceberg, Wen and Klenk wrote. They praised China's quick progress so far with virus surveillance but said more efforts are needed to integrate human and animal illness surveillance and to remove the barriers between veterinarians and physicians.

See also:

Apr 10 Emerg Microbe Infect case report

Apr 10 Emerg Microbe Infect commentary

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