Debt Rattle January 2 2025
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I get to use that new expression’
TRUMPEDUP
https://www.nejm.org/doi/full/10.1056/NEJMc2415890
Critical Illness in an Adolescent with Influenza A(H5N1) Virus Infection
Published December 31, 2024
Copyright © 2024
Highly pathogenic avian influenza A(H5N1) viruses are circulating among wild birds and poultry in British Columbia, Canada.1 These viruses are also recognized to cause illness in humans. Here, we report a case of critical illness caused by influenza A(H5N1) virus infection in British Columbia.
On November 4, 2024, a 13-year-old girl with a history of mild asthma and an elevated body-mass index (the weight in kilograms divided by the square of the height in meters) of greater than 35 presented to an emergency department in British Columbia with a 2-day history of conjunctivitis in both eyes and a 1-day history of fever. She was discharged home without treatment, but cough, vomiting, and diarrhea then developed, and she returned to the emergency department on November 7 in respiratory distress with hemodynamic instability. On November 8, she was transferred, while receiving bilevel positive airway pressure, to the pediatric intensive care unit at British Columbia Children’s Hospital with respiratory failure, pneumonia in the left lower lobe, acute kidney injury, thrombocytopenia, and leukopenia (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). A nasopharyngeal swab obtained at admission was positive for influenza A but negative for A(H1) and A(H3) by the BioFire Respiratory Panel 2.1 assay (BioFire Diagnostics). Reflex testing of the specimen with the Xpert Xpress CoV-2/Flu/RSV plus assay (Cepheid) revealed an influenza A cycle threshold (Ct) value of 27.1. This finding indicates a relatively high viral load for which subtyping would be expected; the lack of subtype identification suggested infection with a novel influenza A virus. Oseltamivir treatment was started on November 8 (Table S2), and the use of eye protection, N95 respirators, and other precautions against droplet, contact, and airborne transmission were implemented.
A reverse-transcriptase–polymerase-chain-reaction (RT-PCR) test specific for influenza A(H5)2 was positive on the day of admission. The patient had signs of respiratory deterioration — chest radiographs were consistent with progression to acute respiratory distress syndrome (Fig. S1) — which prompted tracheal intubation and initiation of venovenous extracorporeal membrane oxygenation (ECMO) on November 9. Continuous renal replacement therapy was initiated on November 10. Combination antiviral treatment with amantadine (initiated on November 9) and baloxavir (initiated on November 11) was added to ongoing treatment with oseltamivir. Bacterial cultures of blood (samples obtained at admission) and endotracheal aspirate (obtained after intubation) yielded no growth.
Because of concern for cytokine-mediated hemodynamic instability, plasma exchange was performed daily from November 14 through November 16. Serial influenza A–specific RT-PCR tests showed increasing Ct values, which suggested a decline in the viral RNA load in serum and a decline in viral RNA in upper- and lower-respiratory specimens shortly after the initiation of antiviral treatment, with the first negative RT-PCR result for serum obtained on November 16 (Table 1). It is notable that lower-respiratory specimens consistently yielded lower Ct values than upper-respiratory specimens, a finding that suggested higher viral levels in the lower-respiratory tract (Table S3).
Table 1Results of Virologic Testing of Clinical Specimens from a Patient with Influenza A(H5N1) Virus Infection, November 2024.
Influenza A(H5N1) virus was cultured from respiratory specimens obtained between November 8 and November 12 but not from subsequent respiratory specimens or from any serum specimens (Table 1). No evidence of reduced susceptibility to any of the three antiviral agents used in treatment was observed in serial respiratory specimens by either genomic analysis or phenotypic testing with the NA-Star influenza neuraminidase inhibitor resistance detection kit (ThermoFisher Scientific) (Table 1). The patient’s respiratory status improved, ECMO was discontinued on November 22, and the patient’s trachea was extubated on November 28.
The viral genome sequence obtained from a tracheal-aspirate specimen collected on November 9 (8 days after the onset of symptoms) was reconstructed as described previously.3 The virus was typed as clade 2.3.4.4b, genotype D1.1,4 most closely related to viruses detected in wild birds in British Columbia around the same time (Fig. S2). Markers of adaptation to humans were detected in the tracheal-aspirate specimen collected on November 9: the E627K mutation was detected (52% allele frequency) in the polymerase basic 2 (PB2) gene product, and analysis of the H5 hemagglutinin (HA) gene yielded ambiguous calls in the codons for amino acid residues E186 (E190 according to H3 mature HA numbering) — 28% allele frequency for E186D — and Q222 (Q226 according to H3 mature HA numbering) — 35% allele frequency for Q222H. The mutations in the H5 HA gene have previously been shown to increase binding to α2-6–linked sialic acids, which act as receptors that facilitate viral entry into cells in the human respiratory tract and enable viral replication.5
Highly pathogenic avian influenza A(H5N1) virus infection acquired in North America can cause severe human illness. Evidence for changes to HA that may increase binding to human airway receptors is worrisome.
Agatha N. Jassem, Ph.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Ashley Roberts, M.D.
British Columbia Children’s Hospital, Vancouver, BC, Canada
John Tyson, Ph.D.
James E.A. Zlosnik, Ph.D.
Shannon L. Russell, Ph.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Jessica M. Caleta, M.Sc.
Public Health Agency of Canada, Winnipeg, MB, Canada
Eric J. Eckbo, M.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Ruimin Gao, Ph.D.
Taeyo Chestley, Ph.D.
Public Health Agency of Canada, Winnipeg, MB, Canada
Jennifer Grant, M.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Timothy M. Uyeki, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA
Natalie A. Prystajecky, Ph.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Chelsea G. Himsworth, D.V.M., Ph.D.
British Columbia Ministry of Agriculture and Food, Abbotsford, BC, Canada
Elspeth MacBain, M.D.
British Columbia Children’s Hospital, Vancouver, BC, Canada
Charlene Ranadheera, Ph.D.
Public Health Agency of Canada, Winnipeg, MB, Canada
Lynne Li, M.D.
British Columbia Children’s Hospital, Vancouver, BC, Canada
Linda M.N. Hoang, M.D.
British Columbia Centre for Disease Control, Vancouver, BC, Canada
Nathalie Bastien, Ph.D.
Public Health Agency of Canada, Winnipeg, MB, Canada
David M. Goldfarb, M.D.
British Columbia Children’s Hospital, Vancouver, BC, Canada
david.goldfarb@cw.bc.ca
Notes
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
This letter was published on December 31, 2024, at NEJM.org.
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.Tesla Self Driving Walkers:
My wife did a number on her right leg breaking her leg and shredding her ankle after Xmas.
We got her home New Years Eve.
She didn’t like our current basic walker because it didn’t have 4 wheels like the hospital ones did.So today, Amazon delivered a 4 wheeled walker with brakes and a small seat.
I told my Wife that we had declined to get the Tesla self driving walker, so it couldn’t spy on her, nor collect and sell her personnal data, nor could it be remotely hijacked by Elon Musk or the government!
She is happy!
Good luck!
You just gave me an idea of how someone can get to the head of the line for knee replacements.
:-0Thanks for the cup sizes video Dr D
I loved the 512oz ‘child’ cup cause it’s the size of a 2 year old!
@jb-hb: Thanks for the insights on being commanded by incompetent bureaucrats who only know generalities.
Show n’ Tell Time with the Shawn Ryan Show w/ Pete Hegseth
Unspeakable Truths from the Horse’s Mouth
Nowhere but TAE do we get the variety and focus. I did not read oroboros post yet, but pieces floating nearby were picked up and put in the puzzle. A lot of someone that was going along with woke decided that team was going to lose. New team. Doesnt contradict the voices here.
Every minute of Parks and Recreation — only Starting Season 2 — is pure gold.
I have lots of ideas and ways to take down the elites, and their equipment as well, which is laughable — they’re a joke — but it mostly involves keeping your mouth shut. If we can’t manage to have secret societies with very grave penalties to discuss it,well, I guess we’ll lose or something. It’ll be a lot longer. And here the Left can put out an Anarchist’s Cookbook, be defended to the nines, and sell books to amputate your kid all day no problem. If I published a book on how easy it is to shut down a Tesla or drop a drone?? My GOD, think of the childrens! If those drones aren’t flying, how is a 9 year old going to get his “Hustler” delivered?
With the moon landing, again, seen and the unseen. Sooo… what WAS on the Apollo rockets? Those ain’t cheap, you know. Why did the USSR — and the entire planet, with no exceptions — keep their mouths shut. There’s more than just the direct set of questions or skepticisms to be solved.
correction:
Vermont Supreme Court Ruling Allows Schools to Administer COVID Vaccines Without Parents’ ConsentVermont Supreme Court Ruling Allows Schools to Administer COVID Vaccines Without Parents’ Consent
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