Up to a third of schoolchildren in some parts of England may already have had swine fluBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5051 (Published 25 November 2009) Cite this as: BMJ 2009;339:b5051
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I can relate to this misdiagnosis. I have, as the medical registrar on-call, seen patients who have been treated initially for swine flu in the community but ultimately found to have alternative significant diagnoses, namely meningitis and recurrent pulmonary tuberculosis.
Physicians should always remember to see the wood from the trees, namely when most will have swine flu, keep an open and vigilant mind for the ones who do not.
Competing interests: None declared
We read the article by Anna Gulland with great interest and would like to make a comment to primary care physicians. A 63 year old Caucasian woman presented to eye casualty with a one week history of headache, nausea and a four day history of a red left eye and reduced vision. On day one she was complaining a left sided headache and pain radiating to her left eye. She was nauseated and had a pyrexia of 39°C . Her symptoms persisted, with the headache not responding to oral Paracetamol. The following day the pyrexia resolved, the headache worsened and she vomited. She describes her left eye becoming “blood shot”. On day two she spoke to her general practitioner (GP) over the phone as she was concerned these may be the symptoms of swine flu and was advised to commence a course of Tamiflu. Three days later her left eye remained painful and in addition her vision became blurred. The headache and nausea continued. She phoned her general practitioner to report the reduction in vision and was advised not to attend the surgery due to possible swine flu. She arranged for a prescription of chloramphenicol ointment to be collected.
The following day her vision continued to deteriorate, she was reviewed by her GP who promptly referred her to our eye casualty.
On examination her visual acuities were right eye 6/9 and left eye Counting Fingers. Right intra-ocular pressure (IOP) was 16 and left IOP was 75 mmHg. She had a left fixed mid-dilated pupil due to iris ischaemia, bilateral narrow anterior chambers, open angle on the right and closed angle on the left. There was marked left anterior chamber inflammation. She was treated with intravenous Acetazolamide, g. Pilocarpine 2% QDS BE, g. Predforte 1 hourly LE, g. Timolol 0.25% BD LE, g. Iopidine TDS LE, g. Alphagan BD LE. She required bilateral YAG peripheral iridotomies. Her vision was Hand Movements in the left eye due to optic nerve damage as a result of left acute angle closure glaucoma.
The diagnosis of swine flu was based on her symptoms of mild pyrexia and headache. She did not have an associated sore throat, cough, shortness of breath or aching muscles. Pyrexia is not a feature of acute angle closure glaucoma, and as a result the initial symptom of blurred vision was not taken seriously by either the patient or GP. On direct questioning she did not compare her unilateral vision in each eye and had not noticed the degree of left visual loss with both eyes open. It is no doubt to difficult to make diagnoses over the phone when a patient is not able to necessarily express symptoms in order of severity. The delay in managing acute angle closure glaucoma unfortunately resulted in this woman having severely impaired vision.
Conjunctivitis has been reported to be associated with swine flu . This presents with red, watery eyes. Our suggestion to primary care physicians would be to carefully question patients complaining of visual symptoms when screening for swine flu.
1. Ball K. The Enigma of the H1N1 Flue: Are You Ready?AORN J. 2009 Dec;90(6):852-66.
2. Sebastian MR, Lodha R, Kabra SK. Swine origin influenza (swine flu). Indian J Pediatr. 2009 Aug;76(8):833-41.
Competing interests: None declared
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