Fulminant, life-threatening influenza A/H1N1 virus infection

History and clinical findings: A 52-year-old man presented with unproductive cough, fever and chill in our emergency department. Self-medication with amoxicillin over 3 days failed to improve his condition. The patient was in poor general condition. His body temperature was 38.4 degrees C, with a heart rate of 124/min, a blood pressure of 120/70 mmHg and a positive shock index. At auscultation of the chest fine rales were heard over both lungs with diminished percussion sounds basal. The respiratory rate was 30/min and the oxygen saturation of 84% at room air. Investigations: Laboratory: signs of inflammation; blood gas analysis: pronounced hypoxemia. A chest radiogram revealed signs of extensive pulmonary infiltrates on both sides. Treatment and course: The patient was admitted to our Intensive Care Unit. He received piperacillin, sulbactam and levoflaxacin, ample fluid and non-invasive ventilation as well as intermittent catecholamine treatment. As there was no clinical improvement the patient was intubated on day 3. On bronchoscopy viral etiology was suspected. At this time the respiratory situation deteriorated. Acute respiratory distress syndrome (ARDS) was diagnosed. An antifungal and antiviral treatment (voriconazol, oseltamivir) was started and a cortisone pulse was attempted. The patient was transferred to another clinic where extracorporeal membranoxygenation (ECMO) was performed on the same day. The following day influenza A/H1N1-test was confirmed. Ten days after transfer, the patient regained spontanous respiration, and he most likely survives the infection. Conclusion: The incidence of influenza (A/H1N1) has increased in Germany and severe and lethal courses have occured. Therefore, the diagnostic and treatment algorithms need to be reconsidered in order to rapidly diagnose and treat infections.