Age: 26.0
Sex: F
Vaccine: FLU(H1N1), FLUX(H1N1)
Symptoms: Acute respiratory distress syndrome, Blood culture negative, Blood pressure systolic increased, Caesarean section, Chest X-ray abnormal
Clinical narrative: Initial case was retrieved from the scientific literature on 15 March 2011. A 26-year-old female patient, with a medical history of mild pregnancy-induced hypertension, received an injection (route and site not provided) on November 2009 of INFLUENZA, manufacturer and lot number not provided. "In February 2010, a 26-year-old previously healthy, gravida 2, para 0, abortus 1 woman at 37 weeks of gestation presented to the emergency room with spontaneous rupture of membranes. The patient had been followed for prenatal care, and had been diagnosed with mild pregnancy-induced hypertension, for which she was not treated. Two days before admission, she developed a dry cough and headache, for which she was seen by her obstetrician and prescribed amoxicillin. She underwent a cesarean delivery on the day of admission owing to failure to progress, and required general anesthesia because of an elevated partial prothrombin time of unknown cause (partial thromboplastin time = 39.5) and concerns for bleeding complications with an epidural. The delivery and anesthesia course were uncomplicated, and the newborn did well. Several hours after extubation following cesarean delivery, the patient became progressively hypoxic, with a fever of 38.9 degrees Celsius. Her physical examination was remarkable for a heart rate of 124 beats per minute, blood pressure of 132/77 mm Hg, and oxygen saturation of 93% on 5 L oxygen by nasal cannula. She was noted to be in moderate respiratory distress, with bilateral rales on lung auscultation. Her complete blood cell count showed a hematocrit of 32.5%, a platelet count of 147 x 10E9/L, and a white blood cell count of 11.2 x 10E9/L, with a differential of 86% neutrophils, 7% lymphocytes, and 7% monocytes; chemistry results were normal. A chest radiograph revealed bilateral infiltrates, and a chest computed tomography showed diffuse, bilateral pneumonitis, both consistent with acute respiratory failure and sepsis, possibly owing to aspiration pneumonia or amniotic fluid embolism. Review of medical records confirmed that the patient had received the inactivated 2009 H1N1 in November 2009 at 25 weeks of gestation; the lot number was confirmed as not having been from a recalled batch. She had not received vaccination with the 2009-2010 INFLUENZA vaccine. In intensive care, the patient required mechanical ventilation and was started on broad-spectrum antibiotics and high-dose steroids. A respiratory specimen tested positive for 2009 H1N1 by polymerase chain reaction, and, on hospital day 3, the patient was started on oseltamivir at 75 mg every 12 hours. Microbiologic testing for bacteria was negative, including urine, blood, and sputum cultures. She subsequently improved and was extubated on hospital day 11 and discharged home 3 days later. Testing of paired sera collected 2 days before symptom onset (obtained as part of a routine blood draw) and 11 days after symptoms onset (during hospitalization) was performed at the   [Due to memory limitations, the remainder of this text could not be compared.]  at the Department of Public Health Viral and Disease Laboratory. The acute serum was negative for antibody to both the 2009 H1N1 strain and SEASONAL INFLUENZA strain by A/Brisbane/59/07 by hemagglutination inhibition (HI) and microneutralization (MN) assays, whereas the convalescent serum was positive for antibody to the 2009 H1N1 (HI=1:640, MN=1:320) but negative for A/Brisbane/59/07. The patient required mechanical ventilation for 11 days, but ultimately improved, and was discharged home on hospital day 14." The outcome was reported as recovered. Documents held by sender: None.