Korean J Pediatr Infect Dis.  2011 Dec;18(2):193-200.

Severe Pneumonia Caused by 2009 Pandemic Influenza A (H1N1) Virus in Children and Corticosteroid Treatment

• Sohn YR
• Kim JH
• Ma SH
• Lee KY
• Kang JH

Abstract

PURPOSE
The effect of corticosteroid on severe pneumonia caused by 2009 pandemic influenza (H1N1) A virus is controversial. This study was aimed to present the effects of early, short-term corticosteroid treatment for severe pneumonia with this virus infection.
METHODS
A retrospective analysis was performed on severe pneumonia patients (37 patients) who had severe respiratory distress at presentation requiring oxygen therapy and received intravenous methylprednisolone (MP, 8-10 mg/kg, divided in 4 doses/day for 2-3 days) with oseltamivir. The clinical and laboratory characteristics of the patients were evaluated through the medical records and chest radiographic findings.
RESULTS
The mean age and male-to-female ratio of the patients were 6.5+/-2.9 years of age, and 3.4:1 (male 29 patients), respectively. The 5-9 aged group was predominant among the age groups (25 patients, 67.6%). Duration of fever prior to admission was 1.4+/-0.6 days and dyspnea developed within 24 h after beginning of respiratory symptoms in all patients. All patients were previously healthy and received oseltamivir within 48 h. Thirteen patients (35.1%) developed dyspnea during oseltamivir treatment. Following MP infusion, all 37 patients including 13 progressive pneumonia patients during oseltamivir treatment showed an immediate halt in the progression of pneumonic infiltration with rapid clinical improvement. There were no side-effects following steroid use.
CONCLUSION
For severe pneumonia patients, early corticosteroid treatment halted clinical exacerbation, and possibly prevented progression to acute respiratory distress syndrome. Further controlled clinical studies are needed for the role of corticosteroids and antivirals on severely affected patients with influenza virus infections.

Keyword

H1N1 influenza virus; Corticosteroid; Pneumonia; Children

MeSH Terms

Adrenal Cortex Hormones
Aged
Antiviral Agents
Child
Dyspnea
Fever
Humans
Influenza, Human
Medical Records
Methylprednisolone
Orthomyxoviridae
Oseltamivir
Oxygen
Pandemics
Pneumonia
Respiratory Distress Syndrome, Adult
Retrospective Studies
Thorax
Viruses
Adrenal Cortex Hormones
Antiviral Agents
Methylprednisolone
Oseltamivir
Oxygen

Reference

1. Neumann G, Noda T, Kawaoka Y. Emergence and pandemic potential of swine-origin H1N1 influenza virus. Nature. 2009. 459:931–939.

2. Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med. 2009. 360:2605–2615.

3. World Health Organization [homepage on the Internet]. Global Alert and Response; [about 2 screens]. c2009. updated 2009 June 11 cited 2009 July 17. Geneva, Switzerland: WHO;Available from: http://www.who.int/csr/diseea/swineflu/frequently_asked_questions/levels_ pandemic_alert/en/index.html.

4. Kim WJ. Novel influenza A/H1N1 pandemic: current status and prospects. J Korean Med Assoc. 2009. 52:787–794.

5. Korean Center for Disease Control. Epidemiology of early detected Novel Influenza A (H1N1) in Korea, 2009. Public Health Wkly Rep. 2009. 2:689–691.

6. Lee HJ, Min SJ, Choi JW, Kang EK. Clinical characteristics of hospitalized pediatric patients with 2009 novel influenza A infection. Pediatr Allergy Respir Dis. 2010. 20:130–137.

7. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza. Bautista E, Chotpitayasunondh T, Gao Z, Harper SA, Shaw M, Uyeki TM, editors. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med. 2010. 362:1708–1719.

8. Falagas ME, Vouloumanou EK, Baskouta E, Rafailidis PI, Polyzos K, Rello J. Treatment options for 2009 H1N1 influenza: evaluation of the published evidence. Int J Antimicrob Agents. 2010. 35:421–430.

9. Reddy D. Responding to pandemic (H1N1) 2009 influenza: the role of oseltamivir. J Antimicrob Chemother. 2010. 04. 65:Suppl 2. ii35–ii40.

10. de Jong MD, Simmons CP, Thanh TT, Hien VH, Smith GJ, Chau TN, et al. Fatal outcome of human influenza A (H5N1) is associated with high viral load and hyper-cytokinemia. Nat Med. 2006. 12:1203–1207.

11. Eichelberger MC. The cotton rat as a model to study influenza pathogenesis and immunity. Viral Immunol. 2007. 20:243–249.

12. La Gruta NL, Kedzierska K, Stambas J, Doherty PC. A question of self-reservation: immunopathology in influenza virus infection. Immunol Cell Biol. 2007. 85:85–92.

13. To KK, Hung IF, Li IW, Lee KL, Koo CK, Yan WW, et al. Delayed clearance of viral load and marked cytokine activation in severe cases of pandemic H1N1 2009 influenza virus infection. Clin Infect Dis. 2010. 50:850–859.

14. Lee KY, Rhim JW, Kang JH. Hyperimmune cells (T cells) may be responsible for acute lung injury in influenza virus infections: a need for early immune-modulators for severe cases. Med Hypotheses. 2011. 76:64–69.

15. Quispe-Laime AM, Bracco JD, Barberio PA, Campagne CG, Rolfo VE, Umberger R, et al. H1N1 influenza A virus-associated acute lung injury: response to combination oseltamivir and prolonged corticosteroid treatment. Intensive Care Med. 2010. 36:33–41.

16. Linko R, Pettila V, Ruokonen E, Varpula T, Sari Karlsson S, Tenhunen J, et al. FINN H1N1-study group. Corticosteroid therapy in intensive care unit patients with PCR-confirmed influenza A (H1N1) infection in Finland. Acta Anaesthesiol Scand. (In press).

17. Confalonieri M, Cifaldi R, Dreas L, Viviani M, Biolo M, Gabrielli M. Methylprednisolone infusion for life-threatening H1N1-virus infection. Ther Adv Respir Dis. 2010. 4:233–237.

18. Roberts C, Nirmalan M, O'Shea S. Steroid-sensitive post-viral inflammatory pneumonitis (PVIP). Am J Respir Crit Care Med. 2010. 182:1089–1090.

19. Kil HR, Lee JH, Lee KY, Rhim JW, Youn YS, Kang JH. Early corticosteroid treatment for severe pneumonia caused by 2009 H1N1 influenza virus. Critical Care. 2011. 15:413.

20. Annane D. Pro: The illegitimate crusade against corticosteroids for severe H1N1 pneumonia. Am J Respir Crit Care Med. 2011. 183:1125–1126.

21. Rhim JW, Lee KY, Youn YS, Kang JH, Kim JC. Epidemiological and clinical characteristics of childhood pandemic 2009 H1N1 virus infection: An observational cohort study. BMC infect Dis. 2011. 11:225.

22. Bettinger JA, Sauvé LJ, Scheifele DW, Moore D, Vaudry W, Tran D, et al. Pandemic influenza in Canadian children: a summary of hospitalized pediatric cases. Vaccine. 2010. 28:3180–3184.

23. Matthay MA, Lia KD. Con: Corticosteroids are not indicated for treatment of acute lung injury from H1N1 viral pneumonia. Am J Respir Crit Care Med. 2011. 183:1127–1128.

24. Kim SH, Hong SB, Yun SC, Choi WI, Ahn JJ, Lee YJ. Corticosteroid treatment in critically ill patients with pandemic influenza A/H1N1 2009 infection: analytic strategy using propensity scores. Am J Respir Crit Care Med. 2011. 183:1207–1214.

25. Brun-Buisson C, Richard JC, Mercat A, Thiébaut A, Brochard L. Early corticosteroids in severe Influenza A/H1N1 pneumonia and acute respiratory distress syndrome. Am J Respir Crit Care Med. 2011. 183:1200–1206.

26. Witkop CT, Duffy MR, Macias EA, Gibbons TF, Escobar JD, Burwell KN, et al. Novel influenza A (H1N1) outbreak at the US Air Force Academy: epidemiology and viral shedding duration. Am J Prev Med. 2010. 38:121–126.

27. Confalonieri M, D'Agaro P, Campello C. Corticosteroids do not cause harmful increase of viral load in severe H1N1 virus infection. Intensive Care Med. 2010. 36:1780–1781.

28. Aviram G, Bar-Shai A, Sosna J, Rogowski O, Rosen G, Weinstein I, et al. H1N1 influenza: initial chest radiographic findings in helping predict patient outcome. Radiology. 2010. 255:252–259.

29. Choi SH, Kang EY, Kim JS, Kim YK. Radiologic review of an outbreak of the pandemic (H1N1) 2009 Virus Infection at a university hospital in Seoul, Korea. J Korean Soc Radiol. 2011. 64:341–350.

30. Korppi M, Don M, Valent F, Calciani M. The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children. Acta Paediatr. 2008. 97:943–947.

31. World Health Organization. Human infection with new influenza A (H1N1) virus: Clinical observations from a school associated outbreak in Kobe, Japan, May 2009. Wkly Epidemiol Rec. 2009. 84:237–244.

32. Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, et al. 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team. Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009. N Engl J Med. 2009. 361:1935–1944.

33. Tang BM, Craig JC, Eslick GD, Seppelt I, McLean AS. Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: A systemic review and meta-analysis. Crit Care Med. 2009. 37:1594–1603.