Case Report

Hematemesis in a 2009 H1N1 influenza patient Abstract

Gastrointestinal bleeding complicating influenza is un- common; the follow is a a report of one such incidence.

As the 2009 H1N1 influenza pandemic continues, a great proportion of the population will be infected allowing rare complications of influenza, and its treatment, to surface. Described below is one such case.

A 12-year-old boy without significant medical history presented to the emergency department (ED) in October of 2009 with a 2-day history of malaise, congestion, cough, and fever. There was no report of dyspnea. He had taken ibuprofen without relief. His vital signs revealed a temperature of 102.9?F, a pulse rate of 120 beats/min, and a blood pressure of 103/64 mm Hg. Physical examination was unremarkable. A rapid influenza test was positive for influenza A. A chest radiograph revealed mild atelectasis without evidence of an infiltrate. The patient was given a prescription for a 5-day course of oseltamivir.

The patient returned to the ED 1 day later with the complaint of hematemesis. The patient reported that he took 1 dose of oseltamivir and was seized with immediate nausea. He had several episodes of emesis culminating in hematemesis with the development of periorbital petichae. There was no report of melena, hematochezia, or light-headedness. His blood pressure was 110/75 mm Hg, with a pulse rate of 116 beats/min. Physical examination was notable for periorbital pete- chiae. A chest radiograph revealed no infiltrates or pneumomediastinum. A complete blood count revealed a hemoglobin level of 14.2 g/dL, platelets of 250, and an International normalized ratio of 1.2. A naso- gastic tube was inserted and returned 60 mL of bright red blood. The patient was transferred to a specialty pediatric hospital. Upon arrival there, a follow-up hemoglobin level was 12.9 g/dL after approximately

1 L of crystalloid infusion. The patient was admitted overnight for observation and treated with proton pump inhibitors and histamine receptor antagonists. No further bleeding occurred, and the patient was discharged from

the hospital the following day. No endoscopic evaluation was performed.

Gastrointestinal bleeding complicating influenza infec- tion can have several etiologies: gastritis secondary to nonsteroidal anti-inflammatory use, esophageal perforation secondary to vomiting from oseltimivir use or direct viral effect, and influenza-related gastropathy. The patient de- scribed above most likely had gastrointestinal bleeding secondary to either ibuprofen-induced gastritis, severe retching from oseltamivir leading to esophageal perforation, or influenza-related gastropathy.

Oseltamivir, the chief antiviral treatment used in cases of influenza incites vomiting in approximately 2.7% of patients-an adverse effect to be weighed when prescribing to patients who are otherwise healthy [1].

Direct involvement of the gastrointestinal tract by the 2009 H1N1 influenza virus is also possible because this virus has been noted to produce symptoms uncharacteristic of Influenza infection, that is, nausea, vomiting, and diarrhea [2].

A literature search on the words “hematemesis” and “influenza” returned a case series from almost 2 decades ago describing 7 cases of hematemesis-some of which were fatal-complicating influenza infection in children in Australia during the 1988 flu season. Salient features of the cases included aspirin use in 1 patient and hemorrhagic gastritis in those patients who underwent endoscopy [3].

Of note, the association of hemorrhagic gastritis with influenza was recognized during the 1918 pandemic, which was caused by a virus somewhat similar to the 2009 H1N1 influenza A virus [3].

The ongoing 2009 H1N1 pandemic provides the opportunity to collate case histories of a large number of patients, whose experiences may elucidate novel aspects of influenza that will further refine our understanding of this disease.

Amesh A. Adalja MD

University of Pittsburgh Medical Center

Pittsburgh, PA 15261, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2009.12.012

0735-6757/$ - see front matter (C) 2010

846.e4 Case Report

References

1. Hayden FG, Atmar RL, Schilling M, et al. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza. N Engl J Med 1999;341:1336-43.
2. CDC. Hospitalized patients with novel Influenza A virus infection -California, April-May, 2009. MMWR Morb Mortal Wkly Rep 2009;19:536-41.
3. Armstrong KL, Fraser DKB, Faoagali JL. Gastrointestinal bleeding with influenza virus. Med J Aust 1991;154:180-2.