Wajima N

Accumulation of air and a retroperitoneal abscess during type B influenza virus infection in an older adult.

Several patients with pandemic and seasonal influenza virus infection have died as a result of the development of pneumonia, acute renal failure and brain edema, despite having received intensive treatment. By contrast, the development of severe gastrointestinal complications from influenza viral infection is uncommon, and limited mostly to symptoms such as diarrhea and vomiting. Furthermore, type B influenza virus is considered to be less pathogenic than type A influenza virus. Here, we describe an elderly patient who died of acute respiratory distress syndrome caused by sepsis as a result of the recurrent retention of a retroperitoneal abscess with air after infection with type B influenza virus. An 81-year-old woman was admitted in February 2014 to Hirosaki Central Hospital in Japan for assessment and treatment of anorexia. For the previous 14 years, she had been treated with vasodilators and warfarin after a myocardial infarction and with prednisolone (7.5 mg/day) for autoimmune hepatitis. A colonoscopy was planned because of a positive fecal occult blood test result, but, overall, the symptoms of anorexia improved during her stay at the hospital. However, she presented with a fever of 39.4°C after 1 month of hospitalization, and type B influenza virus infection was diagnosed after a positive throat swab result from a rapid diagnostic kit. The patient was treated with the neuraminidase inhibitor, peramivir, but she experienced diarrhea 3 days after the initiation of treatment and presented with stomach pain accompanied by severe abdominal tenderness 2 days later. A computed tomography scan of her abdomen showed air accumulation posterior to the pancreas (Fig. 1a). Peripheral blood and serum showed the following signs of inflammation: a white blood cell count of 12 800 cells/μL and a C-reactive protein level of 10.7 mg/dL. By contrast, the peripheral blood lymphocyte count was low (885 cells/μL). In addition, the patient’s systolic blood pressure dropped to 64 mmHg. These findings suggested the presence of septic shock and perforation of the intestine. The patient was then transferred to the hospital of the Hirosaki University Graduate School of Medicine for emergency surgery. During the operation, swelling of the intestinal tissue and an abscess posterior to the pancreas and duodenum were noted, but the macroscopic point of perforation could not be found in the intestinal tissue surrounding the abscess. A bacteriological examination showed the presence of Enterobacter aerogenes and Candida albicans in the abscess specimens. In addition, significant levels of (1, 3)-β-D-glucan (69 pg/mL) and procalcitonin (4.6 ng/mL) were detected in the serum. The patient was treated with antibiotics, as well as the antifungal agent, micafungin, and the protease inhibitor, sivelestat, and catecholamines; she also underwent hemodialysis and mechanical ventilation. However, 29 days after the operation, an abdominal computed tomography scan showed that the abscess posterior to the pancreas and duodenum had increased in size, and also showed the presence of air within the abscess (Fig. 1b). The partial pressure of oxygen (PaO2) in the patient’s arterial blood rapidly decreased to