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Diarrhea and Coma as Presenting Manifestations of Fatal Avian Influenza

Two atypical cases in Vietnam broaden the spectrum of avian influenza and have important implications for surveillance and treatment.

In 2004, 45 cases of avian influenza A (H5N1) infection -- all characterized by severe respiratory symptoms -- were documented in Southeast Asia. A case from Thailand involving fever and diarrhea but no respiratory symptoms has since been described. Now, two additional cases have been reported, one documented and the other probable, both with atypical symptoms.

A 4-year-old Vietnamese boy was hospitalized in February 2004 after 2 days of severe diarrhea, vomiting, fever, and headache. Physical examination and chest x-ray were normal. Over 3 days, he showed rapidly increasing drowsiness and worsening diarrhea, and he was transferred to a pediatric referral hospital. On admission, he was coughing and hypotensive, but his chest x-ray was normal. Twelve hours later, the boy had a generalized convulsion and became comatose. Cerebrospinal fluid (CSF) analysis revealed 1 white cell per mm³, normal glucose, and elevated protein. Respiratory failure soon developed, and a chest x-ray then revealed bilateral infiltrates. The boy died 2 days after transfer. Subsequently, avian influenza A (H5N1) virus was isolated from CSF, serum, and rectal- and throat-swab specimens. The patient's 9-year-old sister had died 2 weeks earlier from a similar syndrome, but no virologic studies were performed. Her fatal illness lasted 5 days and featured severe diarrhea and increasing drowsiness; respiratory symptoms were absent, and chest x-ray was normal. She had swum regularly in a canal frequented by domestic ducks.

Comment: These illnesses are worrisome in that they indicate replication of the H5N1 virus in multiple organs, most notably the central nervous system and gastrointestinal tract. Strikingly, respiratory symptoms were initially absent and did not predominate. Should avian influenza virus begin to spread efficiently in humans, clinicians must remain alert to the possibility of diarrhea and coma as presenting manifestations in order to initiate prompt antiviral therapy and infection-control measures.

— Neil R. Blacklow, MD

Published in Journal Watch Infectious Diseases March 11, 2005

Citation(s):

De Jong MD et al. Fatal avian influenza A (H5N1) in a child presenting with diarrhea followed by coma. N Engl J Med 2005 Feb 17; 352:686-91.

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