I n 2005, Indonesia saw its fi rst patients with highly pathogenic avian infl uenza A(H5N1). 1 Total confi rmed infl uenza A(H5N1) cases now number 141, accounting for just under one-third (32%) of the global total of 443. 2 The circulating 2.1 clade in Indonesia is generally sensitive in vitro to oseltamivir carboxylate, intrinsically less sensitive than clade 1 viruses, and is mostly adamantine resistant. 3, 4 Oseltamivir is the only treatment currently available in Indonesia.
Human infl uenza A(H5N1) mortality rates are high in Indonesia, around 81% (115/141). Independent prog-nostic factors for mortality in 127 Indonesian patients with confi rmed infl uenza A(H5N1) were poverty, delayed oseltamivir treatment, and not being in a cluster. 5 Clustered infections typically prompt screening of suspects and earlier treatment. Other smaller clinical series have also identifi ed late presentation and suggest many other poor prognostic features, such as leukopenia, absolute lymphopenia ( , 1,000/ m L), neutropenia, thrombocytopenia, an elevated plasma lactate dehydrogenase (LDH), corticosteroid use, no osel tamivir or other antiviral treatment, bilateral This report summarizes the clinical and laboratory fi ndings during the management of 22 infl uenza A(H5N1)-infected patients at our hospital in Jakarta, Indonesia. Our experience is similar to that reported by others, but we describe new fi ndings that may bear upon clinical management and identify specifi c areas in need of more detailed investigation.
All patients were admitted to the Respiratory Unit of the Persahabatan Hospital, a referral center for the diagnosis and treatment of human avian infl uenza. All patients with suspected infl uenza A(H5N1) infection had throat and nasal swabs (primary diagnostic respiratory samples) for analysis by real-time reverse transcriptase (RT)-PCR performed at the World Health Organization-approved reference laboratory of the National Institutes of Health Research and Development in Jakarta. This laboratory lacks a biosafety level 3 facility for viral culture. Rectal swabs, endotracheal aspirates, and pleural fl uid were also obtained from a small number of patients as part of their care. All 22 patients in this report were RT-PCRpositive for infl uenza A(H5N1) by throat swab. Patients were managed intensively in an isolation ward equipped with ventilators.
Data were extracted retrospectively from patients' medical notes. We used standard defi nitions of acute lung injury (ALI) and ARDS (ie, a Pa o 2 :F io 2 ratio of , 300 and , 200, respectively; bilateral CXR infi ltrates; and no evidence of left atrial hypertension. 17 Lung-protective ventilation was used for ventilated patients, consistent with the ARDS Network guidelines. 18 Presumptive evidence of a consumptive coagulopathy was defi ned as increased (greater than upper limit of normal [ULN]) D-dimer levels and prothrombin (PT) and activated partial thromboplastin times (aPTT), and a platelet count , 150,000/ m L. Disseminated intravascular coagulation (DIC) was determined using the International Society of Thrombosis and Hemostasis (ISTH) score (platelet count, PT, fi brinogen and fi brinogen degradation). 19 A score Ն 5 is overt DIC and , 5 nonovert DIC.
Pleural fl uid was defi ned as an exudate if the LDH concentration was . 2/3 ULN of serum LDH (ULN = 200 IU/L) or the pleural fl uid-to-plasma ratios of: (1) total protein were . 0.5, or (2) LDH were . 0.6. 20 The Sepsis Organ-related Failure Assessment (SOFA) was used to assess admission illness severity (higher scores indicate greater severity). SOFA scores (up to 4 per organ system) respiratory (Pa o 2 :F io 2 ratio), liver (total bilirubin), and renal (creatinine) functions; level of consciousness (Glasgow Coma Score); mean arterial BP; and coagulation (platelet count). 21 Ethical approval was not considered necessary for this retrospective study.
Of the 139 patients seen between January 2005 and May 2008 with suspected infl uenza A(H5N1) infection, 22 (16%) were confi rmed by RT-PCR examination of throat swabs ( Table 1 ) . Other positive samples for infl uenza A(H5N1) were rectal swab (n 5 2), endotracheal aspirate (n 5 2), bronchial washings (n 5 2), and pleural fl uid (n 5 2).
Eighteen patients or their family members gave a history of contact with chickens; 12 patients were shadowing on the chest radiograph (CXR), ARDS, viremia, high viral loads in respiratory samples, and high plasma cytokine concentrations. [6] [7] [8] [9] [10] [11] [12] The main clinical features of infl uenza A(H5N1) are well described but biased because most of our knowledge derives almost entirely from severely ill, hospitalized patients. Mild disease and asymptomatic seroconversion have been reported in exposed family members and health-care workers, 3, 13, 14 and, rarely, a predominantly gastrointestinal presentation has been identifi ed. 15, 16 Most patients are symptomatic within 7 days of exposure to diseased poultry, but up to 25% of patients do not report poultry/bird exposure. 12 An understated aspect of infl uenza A(H5N1) is its early, nonspecifi c, febrile presentation that invites a broad differential diagnosis, such as dengue, typhoid fever, and the "flu," including the 2009 swineorigin infl uenza. 5, 12 Within the fi rst 2 days of illness, Indonesian patients reported fever (100%), cough (32%), and rhinorrhea (17%), but only 9% reported dyspnea. 5 At hospital admission, 88% and 84% reported cough and dyspnea, respectively, symptoms characteristic of a community-acquired pneumonia.
Onset of dyspnea appears to prompt referral to a higher level of care for diagnosis and further management. The technical nature (ie, polymerase chain reaction [PCR]) of the laboratory diagnosis of infl uenza A(H5N1), particularly in a vast country like Indonesia, limits access to PCR diagnosis to those with severe illness or those known to have been exposed. Diagnostic diffi culty at the early (primary care) or later stages (in hospital) of disease coupled with a low index of suspicion leads to diagnostic and antiviral treatment delays. Certainly, the rapid progression to respiratory failure, necessitating early ventilation, should alert clinicians to the possibility of infl uenza A(H5N1) infection. cally, 21 patients were diagnosed with pneumonia and 1 patient had a mild fl ulike illness.
All patients complained of fever and most complained of dyspnea (20/22) and a productive cough (19/22) . Other symptoms were sore throat (n 5 12), myalgia (11) , vomiting (10), diarrhea (8) , headache (8) , drowsiness (7), runny nose (5), abdominal pain (2), dry cough (2), and spontaneous mucosal bleeding (1) . No one reported sore or red eyes.
Sixteen of 22 patients had leukopenia ( , 4,000/ m L), 15 of 19 had absolute lymphopenia ( , 1,000/ m L), 3 of 19 had a neutropenia , 1,000/ m L, and 13 of 22 were thrombocytopenic ( , 150,000/ m L), including 2 with severe ( , 50,000/ m L) thrombocytopenia ( Table 2 ) The SOFA score ( Table 3 ) ranged from 0 to 12 (median 5); the respiratory component was 0 to 4 (median 4). A higher median SOFA score was associated with death (5.5 vs 2.5, P 5 .0058).
Consolidation (21/22) was the most common CXR shadowing seen during the illness. At presentation, seven and 12 patients had unilateral or bilateral consolidation, respectively. Of these 19, six had a complete able to date the contact for a median incubation period of 2 (1-8) days. All patients were previously well. None were known to have diabetes. The estimated prevalence of diabetes mellitus in Indonesia is 3.8% (8.4 million/220 million population). 22 Counting the fi rst day of reported illness as day 0, the median duration of illness before the fi rst medical contact was 2 days (range 0-7) at a local clinic (n 5 15 patients) or hospital (n 5 7). The numbers of medical contacts before Persahabatan Hospital admission were: 1 (n 5 8 patients), 2 (n 5 11), 3 (n 5 2), and 4 (n 5 1). Before referral to our hospital, 14 patients were prescribed antibiotics; of these, 4 also received oseltamivir.
There were two family clusters: a mother and son and a mother and daughter. All survived except the mother of the son. The son became ill after his mother, and he was prescribed oral oseltamivir immediately after presenting to his general practitioner after 2 days of illness. He took two doses, did not improve, and was referred to our hospital. He was the earliest referral.
Presentation to the Persahabatan Hospital ranged from 3 to 10 days (median 7) of illness. The time to the fi rst dose of oseltamivir was similar: median 7 (range 2-10) because 18 patients received oseltamivir either at our hospital or on the day of transfer by the referring hospital, following consultation with our team. Three severely ill patients died of respiratory failure soon after admission without receiving oseltamivir. Clini- lobe consolidation, but the chest CT scan taken 1 day later showed more extensive disease ( Figs 1, 2 ) . A repeat CT scan 11 days later ( Fig 3 ) , when the patient was clinically much improved, showed partial resolution of the consolidation and dilated bronchi. Four patients developed pneumothoraces (one bilateral, one with a pneumomediastinum) while ventilated. These were treated by chest drainage.
whiteout on one side but without tracheal deviation.
Of the 21 patients with follow-up CXRs, 20 developed a worsening of their shadowing, sometimes within the same day. A total of 17 patients had features consistent with pleural effusions, but thoracic ultrasound was not done for confi rmation.
Only one patient had a normal CXR. She was one of four survivors. Another survivor had right middle 
Respiratory Score Platelet Count Creatinine Score GCS Score Mean AP Score Bilirubin Score Died
When there were ND, the score was assumed to be 0. AP 5 arterial pressure; GCS 5 Glasgow Coma Score; N 5 no; ND 5 no data; Y 5 yes. See Table 2 for expansion of the other abbreviation.
Two of nine patients had sputum-positive samples for Streptococcus pneumoniae and Pseudomonas aeruginosa . One survivor with suspected ventilatorassociated pneumonia had three positive endotracheal aspirates for Klebsiella terrigans , Pseudomonas cepacia , and Acinetobacter baumannii . Of 17 blood cultures, 3 were positive: (1) coagulase-negative Staphylococcus , (2) coagulase-positive Staphylococcus (assumed to be Staphylococcus aureus ), and (3) an a hemolytic Streptococcus .
Three patients died within hours of admission, one of whom was transferred already ventilated. The rest were treated with either standard or double dose (150 mg bid in an adult) oseltamivir. Antibiotics (third and fourth generation cephalosporins, azithromycin, levo/gatifl oxacin, carbapenems, and aminoglycosides) were given to cover community-and hospital-acquired bacterial pneumonias. One patient only received methylprednisolone; one dose (62.5 mg IV) was given but then stopped after he had hematemesis. Eleven patients received 4 to 8 mg/kg daily of IVIG (Gammagard 10%, Baxter; Westlake Village, CA) for 4 days; three survived.
On admission, the median Pa o 2 :F io 2 ratio was 52.6, range 21 to 327, interquartile range 34 to 80 ( Table 2 ) . Only three patients did not have ALI or ARDS; two of these patients survived. Nineteen (17 within 24 h)
Pleural fl uid was obtained from eight patients by thoracentesis (nine were tapped). All pleural fl uid samples were exudates ( Table 4 ). None was sent routinely for bacterial culture. Total and differential white cell counts varied widely; only three patients had lymphocyte-predominant fl uid. There was no relationship between the blood and pleural fl uid total white cell counts ( P 5 .26, Spearman r ). All pleural and blood samples were taken on the same day but not always simultaneously, making fl uid blood glucose ratios unreliable (these have not been shown). About two-thirds of our patients had hyperglycemia in the diagnostic range for impaired glucose tolerance or diabetes mellitus, and most of them were treated with insulin. None of our patients had been on corticosteroids or were known to have diabetes. Hyperglycemia on admission or developing after treatment with steroids has been observed previously in infl uenza A(H5N1) 6,11,23 but has not been identifi ed as a possible poor prognostic factor. By contrast, hyperglycemia was an independent risk factor for increased mortality in patients with severe acute respiratory syndrome whether they had diabetes or not. 24 Suboptimal glucose control is associated with a poor prognosis in critically ill patients, often in association with bacterial sepsis, 25 and important parallels may exist between sepsis and infl uenza A(H5N1). Our suggestive fi ndings here on a limited number of patients emphasize the need for further research.
There was evidence of a mild consumptive coagulopathy in fi ve patients, consistent with the Chinese series 11 (5/26) that also used a soft defi nition familiar to clinicians, but none of our patients met a more robust defi nition of overt DIC. In the Oner et al 26 series, two of their eight patients had ISTH DIC scores of 8 (admission) and 5 (developing later). Published data suggest overt DIC affects a minority of patients with infl uenza A(H5N1) and when present does not usually cause spontaneous bleeding. 11, 12, 26 D-dimer levels in our patients were elevated out of proportion to the PT and aPTT. Concentrations of fi brinogen (an acute-phase protein) were mostly low or normal despite intense infl ammation, a hallmark of severe infl uenza A(H5N1), 8 as evidenced by increased ferritin and CRP levels in most of our patients who had these acute-phase proteins measured. High D-dimer levels and low fi brinogen levels suggest infl uenza A(H5N1) associated fi brinolysis in the absence of DIC. However, we cannot exclude the possibility of clinically inapparent venous thromboembolic disease in some of our patients, as reported in patients with patients required mechanical ventilation within 3 days of admission. The tidal volume was set at Յ 6 mL/kg and all patients required positive end-expiratory pressure of 10 to 15 cm water. One surviving patient developed a clinically suspected ventilator-associated pneumonia.
Patients (n 5 10) with a blood glucose of Ն 200 mg/dL were started on IV insulin. Two patients with diarrhea as part of their presenting illness were positive for infl uenza A(H5N1) virus by rectal swab. No patients had convulsions.
Patients (n 5 18) died between 6 and 16 days after illness onset. Three died within hours of admission, the others between 2 and 6 days. All deaths were due to ARDS; in 15, hypotension necessitating inotropic support also contributed. In the four patients who survived, one was afebrile on admission with mild disease and the three others required ventilation for 7 to 9 days. Their times to fever clearance ranged from 3 to 6 days and their viruses (n 5 3 had serial throat swabs taken) cleared by the second and fourth days of admission for times to viral clearance of 24 (n 5 1) to 72 h (n 5 2).
By univariate analyses, 13 variables were associated signifi cantly ( P Յ .05) with death. Owing to the small number of patients, a multivariate analysis was not done.
The high death rate of patients with human infl uenza A(H5N1) at our tertiary referral hospital in Jakarta accords with the experience elsewhere in Indonesia. At presentation, measures of poor respiratory function were predictive of death, and we have identifi ed hyperglycemia, elevated D-dimer levels, and elevated urea levels as possible poor prognostic features. Some of the pleural and blood biochemical results were obtained several hours apart. Therefore, pleural-serum ratios should be interpreted in that light. L 5 lymphocytes; LDH 5 lactate dehydrogenase; P 5 polymorphs. See Table 3 legend for expansion of other abbreviation. a Infl uenza A(H5N1) positive.
cally ill patients. 37, 38 The admission SOFA score may also be helpful to identify at-risk patients, but this has been developed for "Western" patients with sepsis who often have comorbidities, multiorgan failure, and shock. 21 Whether the SOFA or a pneumonia scoring system in this predominantly respiratory illness is more relevant requires more research focused on affected populations. 39 Four of our patients survived. Of these, only one had mild clinical disease and a normal CXR. Throat swab viral clearance was confi rmed for three patients within 4 days, suggesting sufficient oseltamivir absorption and antiviral effi cacy. 40 By contrast, others have found that continuing infl uenza A(H5N1) replication despite oseltamivir treatment is associated with death. 41 The effi cacy of IVIG is unknown but may have contributed to survival in three of the patients. In China, convalescent serum administered to several infl uenza A(H5N1) patients also appeared benefi cial. 11 Combined immunomodulatory and antiviral drug therapies warrant further research. 42 The primary limitation of our study was the small number of patients, thus restricting statistical power to discern more subtle effects. We also used a somewhat crude classifi cation of the CXR fi ndings by simply classifying the degree of consolidation as . 50% or not and whether consolidation was unilateral or bilateral. Such a system may be helpful to busy clinicians but lacks the fi nesse of other classifi cations. 43 Not all patients were sampled daily for virus detection and no attempts were made to collect specimens to measure oseltamivir concentrations.
In summary, we have identifi ed new clinical features of infection by infl uenza A(H5N1) linked to poor outcomes in our small series of patients. If confi rmed in larger series, they may shed new light on the clinical consequences of human infl uenza A(H5N1) infection.
Author contributions: Dr Soepandi: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. Dr Burhan: contributed to clinical care, laboratory support, data collection and management, statistical analysis, writing the fi rst draft of the manuscript, and reading and approving the fi nal manuscript. Dr Mangunnegoro: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. Dr Nawas: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. Dr Aditama: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. Dr Partakusuma: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. Dr Isbaniah: contributed to data management, writing the fi rst draft of the manuscript, and reading and approving the fi nal manuscript. Dr Ikhsan: contributed to clinical care, laboratory support, data collection, and reading and approving the fi nal manuscript. severe acute respiratory syndrome. 27 Clinicians should be aware that IVIG increases the plasma viscosity that predisposes to arterial 28 and venous 29 thromboembolic disease resulting in elevated D-dimer levels. 30, 31 An elevated urea level was another possible poor prognostic factor, refl ecting a combination of hypercatabolism, dehydration, and renal impairment.
Eight patients ( ‫ف‬ 36%) had pleural effusions confi rmed by thoracentesis, consistent with radiologic data from southern Vietnam. 32 These are the fi rst data confi rming that infl uenza A(H5N1) causes exudative pleural effusions. Fluid values were similar between blood-stained and straw-colored pleural fl uid, suggesting a necrotizing or hemorrhagic pneumonia and not traumatic taps. The LDH values were high, consistent with severe lung parenchymal damage. The total and differential white cell counts varied and are diffi cult to interpret in the absence of histopathologic and bacteriologic data.
Most patients presented late with respiratory failure and features of ARDS. 6,12 ARDS is common in infl uenza A(H5N1) but affects only a minority of patients with the 2009 pandemic infl uenza A(H1N1), which probably refl ects the propensity for infl uenza A(H5N1) to bind to sialic acid receptors in the lower respiratory tract. 33, 34 A high proportion ( ‫ف‬ 23%) developed pneumothoraces despite the use of low tidal volume ventilation. Pneumothoraces can also occur independent of ventilation, 9 underlying the ease with which pneumothoraces can develop in infl uenza A(H5N1) infection. The mechanism is incompletely understood but may be related to the underlying destruction of lung architecture with pneumatocele and pseudocavity formation, and the effects of mechanical ventilation. 32, 35, 36 The optimal ventilation settings in infl uenza A(H5N1) are currently unknown and need more research.
The duration between onset of illness and administration of oseltamivir has been described as a significant risk factor for a fatal outcome. 5, 12 Most of our patients presented soon after illness onset, but treatment delay was in part related to the unavailability of reliable infl uenza A(H5N1) diagnostics below the tertiary care level and a low index of suspicion in the face of a nondescript febrile illness. 5 By contrast, the apparent survivability of infl uenza A(H5N1) among patients diagnosed early incident to exposure to known human cases testifi es to the importance of early diagnosis and treatment. Our fi ndings affi rm the urgent need for simple, affordable, and effective point-of-care diagnostics for this infection.
We identifi ed many factors associated with death, but the numbers were too small to test for independence. However, clinicians should be aware that some of these may be clinically important. It seems prudent to ensure "optimal" control of hyperglycemia, even though defi ning this is problematic in criti-