Case definition is too looseBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3365 (Published 18 August 2009) Cite this as: BMJ 2009;339:b3365
All rapid responses
To the Editor,
We report on a patient with multiple sclerosis (MS) who was confirmed to
have Swine Influenza (influenza A H1N1v) despite the diagnosis being
excluded by the NHS direct Swine Flu hot line.
This is a veterinary nurse with relapsing remitting MS who has been
receiving monthly doses of Natalizumab infusions since 2002. Natalizumab
(Tysabri, Biogen Idec and Elan Pharmaceuticals) is a humanized monoclonal
antibody which targets the á4 subunits of the cellular adhesion molecules
á4b1 and á4b7 integrins 1. Patients on Natalizumab are thus
immunocompromised and are at high risk to develop opportunistic infections
including PML 2 3 4
Three weeks following her last Natalizumab infusion, the patient developed
flu-like symptoms including sore throat, fever and cough. She measured her
temperature at home and found it to be 39.6 C. She took regular Parcetamol
(1gm 6 hourly) and her temperature came back to normal. Two days later
she contacted the NHS direct line for Swine Flu 5 for advice. After
informing the operator of her health status, she was told “since your
temperature is normal you do not have swine flu and there is no need for
treatment or special precaution”. The patient presented five days later
to the Neurology Day Care Unit in our institution for her monthly
Natalizumab infusion. In view of her flu illness, the treatment was
postponed and throat and nose swabs were performed. The results came back
as positive for influenza A H1N1v. The patient was treated with Tamiflu
(Oseltamivir) 75 mg twice a day for five days and made full recovery. Two
healthy healthcare professionals and another MS patient on Natalizumab
were in direct contact with patient in the Neurology Day Case Unit before
she was isolated. In view of being a high risk patient, the second MS
patient was offered anti viral prophylaxis.
It is difficult to differentiate influenza from other respiratory
pathogens on clinical grounds alone. The current strategy of relying on a
clinical diagnosis is already resulting in over diagnosis and unnecessary
exposure to antivirals which leads to side effects in a significant
proportion6. This may also promote the development of anti-viral
resistance 7. Our case demonstrates the opposite risk of under diagnosis
by reliance on non clinical personnel 8and the potential impact of this
policy in the high risk patient groups and its infection control
implications in the hospital setting.
1. Polman CH, O'Connor PW, Havrdova E, Hutchinson M, Kappos L, Miller DH,
et al. A randomized, placebo-controlled trial of natalizumab for relapsing
multiple sclerosis.[see comment]. New England Journal of Medicine
2. Stuve O, Gold R, Chan A, Mix E, Zettl U, Kieseier BC. alpha4-Integrin
antagonism with natalizumab: effects and adverse effects. Journal of
Neurology 2008;255 Suppl 6:58-65.
3. Ismail A, Kemp J, Sharrack B. Melanoma complicating treatment with
Natalizumab (Tysabri) for multiple sclerosis. J Neurol 2009 [Epub ahead
(accessed 12 August 2009)
6. Mark Strong JB, Paul Redgrave. A/H1N1 pandemic: Oseltamivir’s adverse
events BMJ 2009;339:b3249.
The patient whose case is described has given her signed informed consent to publication.
Competing interests: No competing interests
I am concerned that hysteria regarding an initial label of “swine flu” is compromising patient safety by placing them in unsafe environments.
I recently saw a patient labelled with swine flu by our triage nurse who was subsequently placed in our decontamination room. This room lacks adequate monitoring, clinical equipment and rapid access to medically trained personnel. This room is only intended for use for stable patients. My patient was a 30 year old pyrexial, tachycardic and hypotensive gentleman who had classical, clinical features of pyelonephritis. I believe his placement in isolation delayed initial resuscitation. This is against local guidelines that stipulate all unstable patients must be seen in our resuscitation room. After discussion with my colleagues there are at least two other comparable cases in the last fortnight.
I suspect many similar experiences have occurred in other hospitals either as near misses or deaths. An internet search of newspaper headlines and online reports suggest that at least 4 patients initially labelled with “swine flu” have died of sepsis in the last few weeks - two with meningococcal sepsis1,2; one with Cellulitis3; and one with Tonsillitis4. I believe enquiries are underway in each case. In the meantime I urge that all unstable patients are treated promptly in a safe environment despite a label of “swine flu”. This is especially important in the context of new localising symptoms that may cast doubt on the initial diagnosis and hence the need for isolation.
CT2 ACCS – Acute Medicine
Royal Cornwall Hospital Trust
The patient whose case is described has given signed informed consent to publication.
Competing interests: No competing interests