ElNassir ElNigoumi, Haya Mohammed AlKhayyat
influenza A (H1N1) was officially announces as a pandemic universally in June
2009 (1) Although it can lead
to mild clinical illness, some patients diagnosed with H1N1 suffer from less
than mild symptoms and more complications (2). These risks include
more systemic complications like pneumonia and bacterial co-infection.(3).
Swine flu should be closely monitored in the pediatric population ,because the
risk factors and complications may be extremely severe in this specified
population. Also, the disease can easily evolve and be catalyzed to reach
dangerous levels .Some of these severe conditions include chronic lung disease
and neurological conditions. Furthermore,children with acute lymphoblastic leukemia
(ALL) are at a higher risk of
complications when exposed to H1N1 swine flu as a result of their low immunity (4). We present a case of a patient who
presented with H1N1 pneumonia associated with pancytopenia.
This is a three
year old Bahraini boy, who is a known case of Alpha Thalassemia trait.He
presented to the Emergency Department with history of fever, cough and poor
appetite of one week duration. Medical advice was sought at a private hospital
prior to his admission, where he was then transferred to ourhospital by an
ambulance as a case of H1N1 Pneumonia with anemia and thrombocytopenia.He is a
product of full term, normal delivery with a normal birth weight and had no
perinatal complications. His immunization status is up to date and he was
developmentally normal. The boy’s medical history is only significant for Alpha
Thalassemia trait. There was neither a history of previous hospital admissions
nor surgical procedures. Family history was significant for both sickle cell
disease and thalassemia as the father has both conditions.
he was in respiratory distress with mild pallor and high grade fever (40
degrees Celcius). His Oxygen saturation was maintained above 95% in 2 Liters of
Oxygen. Chest auscultation revealed reduced air entry over the right lung with
bilateral crepitations. Physical examination was negative for lymphadenopathy
blood count on admission, showed normal leukocyte count (8.3 x 10^9/L) with
microcytic, hypochromic anemia (8.5 g/dl) and thrombocytopenia (15 x 10^9/L). The
blood film revealed atypical lymphocytes with no blast cells.
In view of
his respiratory symptoms, a chest x-ray was done which showed infiltrations of
the right upper lobe.
was admitted and kept under cardiac monitor.He was started on Tamiflu,
Erythromycin, Vancomycin, Rocephin, Methylprednisolone and bronchodilators.
Also, he received multiple platelet transfusions.
to have fever and a complete blood count was repeated which showedleukopenia (2.83
x 10^9/L) with an absolute neutrophil count of 0, hemoglobin of 7.1g/dl and a platelet
count of 8×10^9/L. Repeated blood film was also negative for blast cells.His
blood culture result was sterile. His antibiotics were changed to Tazocin and
Gentamycin and a Hematologist advice was sought for bone marrow examination to
rule out malignancy and was started on IVIG.
blood film was repeated and showed blast cells. This was followed by Bone
Marrow examination which confirmed the diagnosis of Acute Lymphoblastic
WHO declaration of pandemic of influenza H1N1 in 2009, the new strain of the
virus attracted the interest of scientists to work on the prevention and the
management of the infectionmechanism in immunocompromised cases. Influenza
disease has been a serious health problem in patients with hematological
malignancies undergoing systematic chemotherapy, or hematopoietic stem cell
transplant, even before the emergence of the novel 2009 H1N1 influenza strain.
A few studies have revealed seasonal influenza outbreaks among these patients
and depicted the susceptibility of immunocompromised populations. However, limited
number of studies report that there is a possible association between cancers
and acquirement of influenza in the community and health care facilities, and
consequently influenza can cause criticalhealth problems to cancer patients
done in Turkey 2010, which included 31 children who presented with flu symptoms
in 2009; and were confirmed to have pandemic influenza H1N1 influenza by two step
polymerase chain reaction from nasopharyngealspecimens. Complete blood count
and peripheral smear out of which 4 had bone marrow aspiration for intractable
fever accompanying cytopenia(s), which were later examined by hematologist.
These patients were then evaluated for elevated hemophagyticlymphohistocytosis.
Fisher’s exact test was used to analyze the association between the presence of
an underlying chronic disorder and hospital admission with the development of cytopenia
(9-10). The Turkish study also revealed that four patients with
persistent fever and cytopenia (s) had bone marrow aspiration examination. of
these, 1 had a new diagnosis of acute myeloid leukemia (patient with down
syndrome) and 1 ALL and 1 acute myeloid
leukemia (AML) patient had no hemophagocytosis and were in remission(11)
published in Riyadh in 2013, on 80 children during period of
October 2010–April 2011 included a one-year-old female patient with leukemia
without any history of influenza vaccination coverage who presented with
typical influenza-like disease symptoms including fever > 39?
c, myalgia, pharyngitis, and cough, with no recent travel abroad during the
winter. The authors
concluded that influenza virus’s infection in leukemia
patient was associated with mild symptoms like those of seasonal influenza-like
illness including fever, cough, and sore throat and due to the child’s age and
immunocompromised state one-year-old leukemia in fact, role in the
establishment of co-infection in patients was not linked with the severity of thesymptoms
Most studies, including this report have shown an
association between severely immunosuppressed patients and developing influenza
associated pneumonia. Unfortunately, due to these children’s’
immunosuppression, vaccines such as the seasonal influenza vaccine may be of very
little benefit. The major aim of this report was to identify the association
between the child’s immunocompromised state and pancytopenia with the incidence
of developing viral pneumonia. Data on association of leukemia with H1N1 and
other viral pneumonias is limited and further studies in association with
oncologist and hematologist are required.