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H1N1 Influenza pneumonia in patient with chronic lymphocytic leukemia – case report

Initial experience with the 2009 H1N1-Influenza A (H1N1) suggests that this virus can cause severe disease in immunosuppressed patients such as influenza pneumonia and respiratory failure. We present a case of 41-year old man with chronic lymphocytic leukemia (CLL) who was treated at the University Hospital for Infectious Diseases in February 2011 because of influenza pneumonia. The patient was first diagnosed in 2008, with small tumor mass (TTM 5.7) CLL, Rai stage I. His phenotype was typical for B-CLL, and due to low CD38 expression and trisomy 12 he was not regarded as a patient with adverse prognosis. Although his tumor mass gradually increased over time, he never required specific treatment. Patient was not vaccinated against influenza although recommended by his hematologist. Present illness started on 2/11/2011 with dry cough and low-grade temperature. He was initially prescribed clarithromycin. On 2/16/2011 patient became febrile up to 40 C with shaking chills and productive cough. He was admitted to small local hospital on 2/17/2011 because of bilateral pneumonia. Upon admission, the patient was febrile (40 C), with decreased breath sounds on the left side with fine crackles bilaterally. The remainder of physical examination was unremarkable. Therapy with oseltamivir, ceftriaxone and doxycycline was commenced. On the fifth day of hospital stay patient’s condition started to deteriorate with development of respiratory insufficiency and he was transferred to Intensive Care Unit (ICU) where mechanical ventilation was started. Ceftriaxone was changed to meropenem and vancomycin ; doxycycline and oseltamivir were continued. Unfortunately, respiratory insufficiency worsened and extracorporeal membrane oxygenation was considered as only life-saving procedure. He was transferred to ICU of University Hospital for Infectious Diseases on the twelfth day of illness. Upon admission patient was mechanically ventilated (fiO2 100%) and hypoxemic (satO2 80%). Pulmonary X-ray showed bilateral confluent, mixed alveolar and interstitial infiltrates, consistent with acute respiratory distress syndrome (ARDS). ECMO was started upon admission. On the seventh day of hospitalization there was further deterioration of patient’s condition, probably because of nosocomial sepsis with development of septic shock and multiple organ dysfunction syndrome. Patient died on the tenth day of hospitalization, i.e. twenty-first day of influenza illness. Diagnosis of influenza A-H1N1 was confirmed by RT-PCR from tracheal aspirate. CLL patients are particularly at risk for influenza complications because of hypogammaglobulinemia and deficient T-cell compartment. Therefore physicians should strongly encourage their patients to get influenza vaccine. Otherwise, during influenza season empirical therapy with oseltamivir should be started at the first symptoms of influenza.

H1N1 influenza pneumonia; chronic lymphocytic leukemia

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