Clinical course of avian influenza A(H5N1) in patients at the Persahabatan Hospital, Jakarta, Indonesia, 2005-2008.
BACKGROUND
Limited understanding of the presentation and course of influenza A(H5N1) infection in humans hinders evidence-based management.


METHODS
We reviewed the case records of patients admitted to the Persahabatan Hospital (RSP), Jakarta, Indonesia, with influenza A(H5N1) confirmed by real-time polymerase chain reaction.


RESULTS
Twenty-two previously well patients, aged 3 to 47 years (median 24.5 years), were identified. All attended a clinic or hospital after a median of 2 days of illness (range 0-7). Times to first dose of oseltamivir (three died before receiving oseltamivir) were 2 to 12 days (median 7 days), administered mostly (n = 15) at RSP. Nineteen patients required mechanical ventilation. Deaths numbered 18 (case fatality = 82%) occurring within hours to 6 days of RSP admission, corresponding to 6 to 16 days of illness. Admission hyperglycemia ( >or= 140 mg/dL), unrelated to steroids or known underlying diabetes mellitus, and elevated D-dimer levels (0.81-5.2 mg/L, upper limit of normal < 0.5 mg/L) were present in 14/21 (67%) and 20/21 (95%) patients, respectively. Fibrinogen concentrations were mostly low/normal at 129.9 to 517.9 mg/dL (median 241.1, normal 200-400 mg/dL), whereas C-reactive protein (9/11) and ferritin (6/8) levels were increased. Risk factors for death (univariate analysis) included: (1) increased D-dimers, (2) hyperglycema, (3) increased urea, (4) more extensive chest radiograph shadowing, and (5) lower admission oxygen saturation.


CONCLUSIONS
Early diagnosis and effective treatment of human influenza A(H5N1) infection remains challenging. Most patients were referred late with advanced disease. Oseltamivir had limited clinical impact. Elevated D-dimer levels, consistent with fibrinolysis, and hyperglycemia warrant more research to determine their underlying mechanisms and optimal treatment.
Rumah Sakit Persahabatan, Jakarta timur, Indonesia.
Priyanti Z
PZ
Soepandi
Erlina
E
Burhan
Hadiarto
H
Mangunnegoro
Arifin
A
Nawas
Tjandra Yoga
TY
Aditama
Lia
L
Partakusuma
Fathiyah
F
Isbaniah
Mukhtar
M
Ikhsan
Boedi
B
Swidarmoko
Agung
A
Sutiyoso
Suhud
S
Malik
Rachel
R
Benamore
J Kevin
JK
Baird
Walter R J
WR
Taylor
D000293:Adolescent; D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D006801:Humans; D007214:Indonesia; D053124:Influenza A Virus, H5N1 Subtype; D007251:Influenza, Human / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D008875:Middle Aged; D053139:Oseltamivir / Q000627:therapeutic use; D010996:Pleural Effusion / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy; D012121:Respiration, Artificial; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
D000998:Antiviral Agents; D053139:Oseltamivir