Severe necrotizing pneumonia in a child with pandemic (H1N1) influenza.

region, a five-year-old girl with mild asthma presented to the emergency department of a children’s hospital in acute respiratory distress. She had an 11-day history of cough, rhinorrhea and progressive chest discomfort. She was otherwise healthy, with no history of severe respiratory illness, prior hospital admissions or immu nocompromise. Outside of infrequent use of salbutamol, she was not taking any medications, and her routine childhood immunizations, in cluding conjugate pneumococcal vaccine, were up to date. She had not received the pandemic influenza vaccine because it was not yet available for her age group. The patient had been seen previously at a community health centre a week into her symptoms, and a chest radiograph had shown perihi lar and peribronchial thickening but no focal con solidation, atelectasis or pleural effusion. She had then been reassessed 24 hours later at an influenza assessment centre and empirically started on oseltamivir. Two days later, with the onset of vomiting, diarrhea, fever and progressive shortness of breath, she was brought to the emergency department of the children’s hospital. On examination, she was in considerable distress; her heart rate was 170 beats/min, her respiratory rate was 60 breaths/min and her blood pressure was 117/57 mm Hg. Her oxygen saturations on room air were consistently 70%. On auscultation, she had decreased air entry to the right side with bronchial breath sounds. Repeat chest radiography showed almost complete opacification of the right hemithorax, air bronchograms in the middle and lower lobes, and minimal aeration to the apex. This was felt to be in keeping with whole lung consolidation and parapneumonic effusion. The left lung appeared normal. Blood tests done on admission showed a hemoglobin level of 122 (normal 110–140) g/L, a leukocyte count of 1.5 (normal 5.5–15.5) × 10/L (neutrophils 11% [normal 47%] and bands 19% [normal 5%]) and a platelet count of 92 (normal 217–533) × 10/L. Results of blood tests were otherwise unremarkable. Venous blood gas had a pH level of 7.32 (normal 7.35–7.42), partial pressure of carbon dioxide of 43 (normal 32– 43) mm Hg, a base deficit of 3.6 (normal –2 to 3) mmol/L, and a bicarbonate level of 21.8 (normal 21–26) mmol/L. The initial serum creatinine level was 43.0 (normal < 36) μmol/L and the urea level was 6.5 (normal 2.0–7.0) mmol/L, with no clinical evidence of renal dysfunction. Given the patient’s profound increased work of breathing, she was admitted to the intensive care unit (ICU), where intubation was required because of her continued decline over the next 24 hours. Blood cultures taken on admission were negative. Nasopharyngeal aspirates were negative on rapid respiratory viral testing, but antiviral treatment for presumed pandemic (H1N1) influenza was continued given her clinical presentation, the prevalence of pandemic influenza in the community and the low sensitivity of the test in the range of only 62%. Viral cultures were not done. Empiric treatment with intravenous cefotaxime (200 mg/kg/d) and vancomycin (40 mg/kg/d) was started in the ICU for broad antimicrobial coverage, including possible Cases