key: cord-0042637-egmmdpvy
authors: Hongjun, LI; Ning, LI
title: Diagnostic Imaging of Chest
date: 2012-12-26
journal: Radiology of Influenza A (H1N1)
DOI: 10.1007/978-94-007-6162-9_11
sha: 81656a7610cf7839b04ebc52dff233ffc29aa5a9
doc_id: 42637
cord_uid: egmmdpvy

Influenza A(H1N1) is caused by the conflict of interest between giant organisms and microorganisms. Influenza A and B viruses are single stranded RNA envelope virus composed of 890–2,341 nucleic acids in eight segmented genomes. Presently, only the virus subtypes of H1N1 and H3N2 still spread from human to human. The viruses spread and replicate under the following conditions: (1) the viruses enter the human body and duplicate there; (2) the viruses cause diseases; and (3) the viruses can easily spread from person to person. The H1N1 influenza viruses replicate is within only respiratory epithelial cells. The virus entering into the cells causes complex pathological changes of the cells. The columnar epithelial cells stop the self-synthesis of cellular component proteins. Therefore, the cells die due to their lack of necessary cell component proteins.

In fl uenza A (H1N1) is caused by the con fl ict of interest between giant organisms and microorganisms. In fl uenza A and B viruses are single stranded RNA envelope virus composed of 890-2,341 nucleic acids in eight segmented genomes. Presently, only the virus subtypes of H1N1 and H3N2 still spread from human to human. The viruses spread and replicate under the following conditions: (1) the viruses enter the human body and duplicate there; (2) the viruses cause diseases; and (3) the viruses can easily spread from person to person. The H1N1 in fl uenza viruses replicate is within only respiratory epithelial cells. The virus entering into the cells causes complex pathological changes of the cells. The columnar epithelial cells stop the selfsynthesis of cellular component proteins. Therefore, the cells die due to their lack of necessary cell component proteins.

In fl uenza A (H1N1) spread from person to person by water duplets (>5 m m) coughed or sneezed out from the nose and throat of infected people. These particles cannot stay in the air, but spread the disease by contacts. The contacts can be direct skin contact or indirect respiratory secretions contact, the latter of which refers to touching his/her own eyes, nose or mouth with his/her own contaminated hands. The patients can spread the virus from 2 days prior to symptoms onset to fi fth day after symptoms onset. The infection time of swine-origin in fl uenza A virus (S-OIV) during its incubation period is about 2-7 days. According to data analysis, most patients infected by S-OIV may have their symptoms onset 1 day in advance, or 5-7 days after being infected. The infection period may be prolonged in immunocompromised children or patients with severe psychiatric disorders. It has been unknown whether a infected asymptomatic person is the source of infection, which deserves detailed research. Severe cases and death cases are mostly caused by the occurrence of its complications, including primary viral pneumonia and secondary bacterial pneumonia (especially group A streptococcus, Staphylococcus aureus and Streptococcus pneumoniae ). Dyspnea, acute respiratory distress syndrome (ARDS) and multiple organs failure are fatal clinical signs of In fl uenza A (H1N1). The average period from symptoms onset to death is about 9 days.

In fl uenza A (H1N1) virus is particularly prone to virus variation. Based on the studies about the variation of In fl uenza A (H1N1) virus, it has been believed that the new human pathogenic mutant has completed its genetic fragments combination in the animal body before its direct invasion into human body. The genetic segments studies of in fl uenza virus from the in fl uenza pandemic in the year of 1918 found genes similar to swine and bird fl u viruses. Therefore, it is believed that the in fl uenza A pandemic in 1918 was caused by the integration of human in fl uenza virus to a segment of DNA from swine in fl uenza virus to form H1N1 in fl uenza virus that is af fi nitive to human body. Based on the belief, experts speculate that the gene recombination of the bird fl u virus with human fl u virus would cause global in fl uenza pandemic. Other scholars also put forward the theory of twice crossing and the model of birds → human → swine. In this model, the bird fl u viruses spreading in poultry animals cross the species boundary to infect other animals, such as pigs, horses, whales or sables. Following the fi rst crossing, the viruses cross the species boundary again to infect human. Some scholars insist on the theory of viruses genes mixer, namely the well-known quick infection of both human fl u viruses and bird fl u viruses to swine, and swine acts as a viruses genes mixer (to recombinate virus strains from two different species). Therefore, the swine fl u virus containing human fl u virus gene emerges, which can proliferate in human body and spread from person to person. WHO recommends the realtime quantitative RT-PCR to detect seasonal fl u, including seral A, B, H1 genes, proteins H3 and bird fl u H5 virus. Using probes and primers to detect A-H1N1 fl u virus, nucleotide sequence analysis and systematic culture analysis, the infection of human MDCK cells by In fl uenza A (H1N1) virus can be con fi rmed. After reverse transcribed ampli fi cation sequencing and following PCR ampli fi cation Diagnostic Imaging of Chest 11 production, the overlapping double-stranded DNA in in fl uenza virus genome can be ampli fi ed. Genome degradation and sequence variation of about every 200-500 nucleotides cause prolonged existence of H1N1 in fl uenza virus.

The incubation period of In fl uenza A (H1N1) viruses is usually about 7 days. The onset of In fl uenza A (H1N1) is acute, with its symptoms being similar to common in fl uenza, including typical fever, general upset, muscular soreness and pain, sore throat, runny nose and cough, possible eye conjunctivitis, possible nausea, abdominal pain and diarrhea. The cases with persistent high body temperature should be given focused attention. According to the clinical review on 18 cases of S-OIV infection treated in a Mexico hospital, S-OIV infection is a serious illness associated with death. Most patients were previously healthy and suffered from pneumonia from day 5 to 7 after the onset of fl u-liked symptoms. In them, seven patients were hospitalized at the day of clinic visit suffering from acute pulmonary impairment or acute respiratory distress. Multiple organs failure occurred in all the seven cases. S-OIV infection commonly occurs in the elderly and children and the ages of more than half of the patients range from 13 to 47 years. The age distribution of S-OIV is similar to that of Mexico in fl uenza epidemic in 1918. Research data of In fl uenza A (H1N1) indicates that a large number of death is related to bacterial infection. However, the 14 cases with complicated bacterial infections out of 18 cases in Mexico review had no serious outcomes, which may be related to the early use of antibiotics before hospitalization.

The etiological detections include isolating In fl uenza A (H1N1) virus from the respiratory secretions, or detecting H1N1 in fl uenza virus A genes by RT-PCR, or detecting the serum antibodies and increased titer by laboratory tests. Most cases may have decreased white blood cells counts, but occasionally the white blood cells count may increase due to the secondary bacterial infection. Lymphocyte count commonly decreases, with normal count of platelets. Bone marrow puncture shows active cells proliferation, reactive histiocytosis with accompanying hemorrhagic phagocytosis. Patients may have increased ALT. Throat swabs is negative to bacterial culture. The most reliable laboratory evidence is the increased dehydrogenase. Increased lactic dehydrogenase usually indicates myocarditis.

The In fl uenza A (H1N1) virus is the primary cause of pulmonary impairments. The virus may directly impair the epithelial cells of respiratory tract. It can also target on alveoli to cause diffusive fi brosis of the pulmonary tissues and alveolar impairments of congestion, edema, surface exudation of viscous liquid, foam liked exudates in small bronchi and bronchioles and large amount of mixed sero fi brin in chest cavity. The pathological examinations of two death cases in Hong Kong showed that the reactive hemophagocytic syndrome is histologically prominent. Other pathological fi ndings include diffusive alveolar impairments with accompanying fi brosis, extensive hepatic centrilobular necrosis, acute renal tubular necrosis, lymphocytes function failure and increased levels of soluble IL-2 receptor, IL-6, g -interferon. Therefore, it is believed that alveoli are the targets of In fl uenza A (H1N1) virus. It replicates in the respiratory tract and the high cytokines is produced by reactive hemophagocytic syndrome. The fi ndings suggest that the pathogenic mechanism of In fl uenza A (H1N1) virus infection may be different from the infection of H1-H3 subtypes of human in fl uenza viruses.

Diagnostic imaging studies contribute to an objective assessment of pulmonary impairments and early diagnosis of their complications, which is of great importance to the prognosis of patients with In fl uenza A (H1N1) virus infection. According to overseas research, delayed treatment for patients with In fl uenza A (H1N1) virus infection may result in serious illness and even death. WHO announced that the global death rate of In fl uenza A (H1N1) virus infection is up to 6.4 %. Therefore, large scaled clinical research is necessary for understanding the pathological progression of In fl uenza A (H1N1) and its complications by data analysis of diagnostic imaging. The more knowledge about its pathological progression will facilitate the early diagnosis.

According to a report published by New England Journal of Medicine [ 1 ] , X-ray of 18 cases of In fl uenza A (H1N1) had fi ndings of alveolar exudation and fusion (commonly in the pulmonary basal segments) of both lungs, reticular or nodular shadows (interstitial exudation), parenchymal changes and occasional pleural effusions. The abnormal demonstrations usually occur in lower lungs, with alveolar exudation and fusion into blurring cloudy shadows, blurred costophrenic angle. The condition may further pathologically progress into large fl aky dense parenchymal shadows. Also in this report, CT scanning found early manifestations of thickened pulmonary markings and punctiform exudates in the right lower pulmonary segment, infused mist liked lobular in fi ltration. Along with the progression of the condition, large fl aky parenchymal shadows in the right lower pulmonary segment was found with involvement of the lung periphery, blurry upper boundary of the diaphragm, the blunt costophrenic angle, increased and blurry bilateral hili. CT scanning of the right lower lung found dense parenchymal shadows, visible lung tissues containing gas shadows with blurry boundaries. After treatment, the foci can be quickly absorbed. Most mild cases have favorable prognosis and for some cases, the disease progresses rapidly. With progressive development of pneumonia, respiratory distress syndrome, respiration failure, heart failure, kidney failure and infectious shock may occur to cause death.

In clinical diagnosis, In fl uenza A (H1N1) should be differentiated from in fl uenza, the common cold, bacterial pneumonia, the infectious severe acute respiratory syndrome (SARS), the infectious mononucleosis, cytomegalovirus infection, chlamydia pneumonia and the mycoplasma pneumonia.

Generally speaking, the con fi rmative diagnosis technology for In fl uenza A (H1N1) is well-developed. The In fl uenza A (H1N1) virus spreads through the respiratory tract, targeting on alveoli and causing diffusive fi brosis of pulmonary tissues and alveolar impairments. There are alveolar edema, large amounts of lobular in fl ammatory exudation and fusion. The diagnostic imaging demonstrates fl acky blurry shadows. With the progression of the disease, the pulmonary interstitial tissues are involved with decreased gas content in alveoli. Parenchymal changes and fi brosis of pulmonary tissues occur. The diagnostic imaging demonstrates large fl aky dense shadows, with blurry surrounding tissues. Based on the diagnostic imaging studies about the pathological progression of In fl uenza A (H1N1) complicated pulmonary diseases, large scale clinical studies have not been conducted both domestically and internationally. Such research fi eld is still blank domestically. Detailed research in such a fi eld will be bene fi cial to clinical observation and objective assessment of the progression of In fl uenza A (H1N1). Therefore, effective control and mortality decrease can be realized. In other words, it is of great signi fi cance in improving public health of human being.

Case History . An 8-years-old boy, with a foreign nationality. He complained of fever and slight cough for 3 days, with no chills and fatigue.

Past History . Not found. Epidemiological History . He was from the epidemic area of In fl uenza A (H1N1).

Signs . Body temperature 39 °C. Pharynx congestion and tonsillar enlargement of I degree.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, white blood cells count 5.3 × 10 9 /L, lymphocytes 53.5 %, and neutrophils 34.5 %.

Diagnostic Imaging . On June 25th, 2009 ( Fig. 11 .2 ): chest X-ray demonstrated thickened pulmonary markings, fl aky and fl ocky shadows with blurry boundaries, enlarged and thickened pulmonary hilus.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 14-years-old female, with a foreign nationality. She complained of fever and cough for 2 days, with chills, shivers, sore throat and slight cough. Past History . Not found. Contact History . Have a history of contact to patients with In fl uenza A (H1N1).

Signs . Body temperature 38.7 °C. Pharynx congestion and tonsillar enlargement of I degree.

Laboratory History of Present Illness . A 12-years-old boy complained of fever for 3 days, with chills and fatigue.

Past History . Not found. Contact History . The boy had a contact history to patients with In fl uenza A (H1N1) and he came from the epidemic area of In fl uenza A (H1N1).

Signs . Body temperature 39.1 °C. Throat red and tonsils no enlarged.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus negative.

By routine blood tests on June 15th, 2009, white blood cells count 4.1 × 10 9 /L, lymphocytes 62.1 % and neutrophils 26.6 %.

By routine blood tests on June 18th, 2009, white blood cells count 5.5 × 10 9 /L, lymphocytes 50.2 % and neutrophils 41.2 %.

Diagnostic Imaging On June 14th, 2009 ( Fig. 11.3a ) : chest X-ray demonstrated increased and deranged pulmonary markings with punctiform blurry shadows, increased and thickened pulmonary hilus.

On June 15th, 2009 ( Fig. 11.3b ) : chest X-ray demonstrated slightly thickened pulmonary markings of both lungs, no other abnormal density shadows in both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests on Nov. 9th, 2009, white blood cells count 13.8 × 10 9 /L and neutrophils 96 %. And by blood gas analysis, pH 7.492, Pace 2 39.5 mmHg and PaO 2 44.6 mmHg.

By routine blood tests on Nov. 11th, 2009, white blood cells count 4.13 × 10 9 /L, lymphocytes 44.6 % and neutrophils 31.8 %. By blood gas analysis, pH 7.406, Pace 2 43.4 mmHg and PaO 2 73.9 mmHg.

Diagnostic Imaging On Nov. 9th, 2009 ( Fig. 11.4a ) : chest X-ray demonstrated stripped and fl aky shadows in both lung fi elds, with blurry boundaries; enlarged and thickened pulmonary hilum.

On Nov. 12th, 2009 ( Fig. 11 .4b ): chest X-ray demonstrated stripped and small fl aky shadows in both lung fi elds, with the sizes obviously decreased.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests, white blood cells count 11.2 × 10 9 /L, lymphocytes 65.4 % and neutrophils 23.8 %.

Diagnostic Imaging On Oct. 13th, 2009 ( Fig. 11 .5a ): chest X-ray demonstrated enhanced pulmonary markings of both lungs, punctiform blurry shadows of both lungs, enlarged and thickened pulmonary hilum.

On Oct. 19th, 2009 (Fig. 11 .5b ): chest X-ray demonstrated clear pulmonary markings of both lungs, no abnormal density shadows in both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 5-years-old boy complained of fever and cough with sputum, with no chills and shivers but with accompanying general fatigue, muscular soreness and pain, poor appetite. Past History . No related past history was found. Contact History . He denied the contact history with In fl uenza A (H1N1) patients.

Signs . The child is conscious with poor spirituality. He has dyspnea, nasal fl aring and frequent rales of both lungs. His breathing rate 40 times/min, heart rate 130 beats/min and a body temperature 39 °C.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, white blood cells count 1.9 × 10 9 /L, PLT 87 × 10 9 /L, neutrophils 60.9 %, ALT 13.2 U/L and AST 30.9 U/L.

His blood oxygen saturation 79-85 %, heart rate 137 beats/min, blood pressure 96/50 mmHg and breathing rate 50 times/min. Diagnostic Imaging . On Nov. 12th, 2009 ( Fig. 11.6a ) : chest X-ray demonstrated diffusive dense blurry shadows of both lungs, unclearly de fi ned pulmonary hilum and blurry upper boundary of diaphragm.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1).

Histopathological Analysis . Figure 11 .6b, c demonstrated intraalveolar bleeding and in fl ammatory cells in fi ltration. History of Present Illness . A 8-years-old boy, a primary school student, complained of fever, cough and being out of breath for 2 days. The fever had no obvious incentives with a body temperature up to 39 °C. The fever showed no regularity, and the cough paroxysmal with a few yellowish thick phlegm, and accompanying out of breath, shortness of breath and chest distress. The boy also suffered from dif fi culty swallowing and occasional abdominal pain, which was obvious during coughs, especially at periumbilical area. Past History . The boy was diagnosed as having asthma at the age of 3 years. He has twice episodes of asthma, with favorable outcomes after treatment. His mother had a history of asthma.

Contact History . The boy had a contact history with suspected cases of fever. Had a contact history with In fl uenza A (H1N1) patients. There were several de fi nitive cases of In fl uenza A (H1N1) in the school he was studying in.

Signs . Body temperature 37.9 °C, heart rate 117 beats/ min, breathing rate 33 times/min, blood pressure 105/60 mmHg. His lips no cyanosis and pharynx obviously congested. The posterior wall of pharynx without follicles hyperplasia and no leukoplakia. Both antiadoncus to II degrees. Auscultation of both lungs found occasional fi ne moist rales and wheezing sound.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, Hb 118 g/L, white blood cells count 6.69 × 10 9 /L, neutrophils 78.1 %, lymphocytes 12.7 % and mononuclear cells 7 %. By blood biochemistry, CK 2022.5 U/L, CK-MB 35.1 U/L, AST 52.5 U/L, muscle calcium protein 1.08 ng/mL, CD3 + T lymphocytes 332/ m L, CD4 + T lymphocytes 173/ m L, CD8 + T lymphocytes 106/ m L and CD4 + /CD8 + On Nov. 5th, 2009 ( Fig. 11 .9d ): chest X-ray demonstrated blurry pulmonary markings of both lungs, diffusive spotty shadows in both lungs, decreased transparency of both lungs and the conditions progressed compared to the previous imaging results.

On Nov. 7th, 2009 ( Fig. 11 .9e ): chest X-ray demonstrated blurry pulmonary markings of both lungs, almost the same as the previous imaging results.

On Nov. 10th, 2009 ( Fig. 11 .9f ): chest X-ray demonstrated increased pulmonary markings of both lungs, blurry pulmonary markings of the right lower lung, and improved conditions compared to the previous imaging fi ndings.

On Nov. 17th, 2009 ( Fig. 11 .9g ): chest X-ray demonstrated no obvious abnormities in cardiopulmonary diaphragm.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 10-years-old boy complained of cough, spasmodic breathing with accompanying fever, sore throat and headache for 3 days. Past History . He was diagnosed as having bronchial asthma 4 years ago.

Contact History . He had a history of contact with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion obvious, body temperature 37.7 °C, heart rate 156 beats/min, blood pressure 135/65 mmHg. Slow reaction, slight irritation, tachypnea, slight cyanosis on face and lips.

Nasal fl aring and three depressions sign positive, coarse breathing sounds, occasional wheezing, and fi ne bubbling from the right side.

Laboratory Tests By throat swabs, universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests on Nov. 30th, 2009, leukocyte count 7.77 × 10 9 /L, neutrophils 91.4 % and lymphocyte 5.5 %.

By blood gas analysis, pH 7.306, PaCO 2 49.9 mmHg, PaO 2 51.9 mmHg, 3 HCO -24.2 mmol/L, BE 1.3 mmol/L, myocardial enzyme spectrum CK 1,591 U/L with obvious increase.

By blood biochemistry, K + 3.7 mmol/L, Na + 132 mmol/L, free Ca 2+ 1.15 mmol/L, Cl − 109 mmol/L, blood glucose 9.2 mmol/L, CPR 20 mg/L, mechanical ventilation.

Diagnostic Imaging On Oct. 30th, 2009 ( Fig. 11 .12 ): chest X-ray demonstrated small fl aky shadows with uneven densities in the left upper lung, the shadows connecting to the upmost of the left pulmonary hilum, increased density of the left pulmonary hilum, thickened and increased pulmonary markings of both lungs that were blurry, occasional reticular shadows of both lungs and slightly increased transparency of both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Case 11.14 History of Present Illness . A 6-years-old boy with acute onset and quick progression. He complained of fever, cough, headache, vomiting, dyspnea; being unable to lie on his back, with unconsciousness and no responses to verbal commands. Past History . None related to the present illness. Contact History . He had a history of contact with In fl uenza A (H1N1) patients.

Signs . Shallow and short breathing, slight cyanosis on face and lips. Throat congestion. The pupils in the same size with slight sluggish reaction to light. Three depressions sign positive. Respiratory sounds of both lungs coarse, with weaker respiration sounds of the left lung and wheezing, dry and moist rales of both lungs. Body temperature 38.2 °C, heart rate 178 beats/min, blood pressure 150/76 mmHg. By routine blood tests, leukocyte count 28.85 × 10 9 /L, neutrophils 86 %, lymphocytes 6.6 %, hemoglobin 119 g/L.

By blood gas analysis, PaCO 2 66.4 mmHg, PaO 2 33.1 mmHg, 3 HCO -20.4 mmol/L and BE 7.7 mmol/L. By blood biochemistry, K + 4.9 mmol/L, Na + 129 mmol/L, Ca 2+ 1.26 mmol/L and blood glucose 8.6 mol/L. Diagnostic Imaging On Oct. 24th, 2009 ( Fig. 11.14a ) : chest X-ray demonstrated irregular patchy shadows with slightly higher density in the left intrapulmonary strip, with blurry boundaries and partially undisplayed heart margin and mediastinum. Increased pulmonary markings in the right intrapulmonary strip and the right pulmonary hilum. Occasional granular reticular shadows in the right pulmonary inner-middle strip. Increased transparency of both lungs. Blunt diaphragmatic angle.

History of Present Illness . A 10-years-old boy complained of fever for 30 h without obvious causes, with accompanying nausea.

Past History . None related to present illness. Contact History . He had a history of contact with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C, heart rate 138 beats/ min, blood pressure 129/75 mmHg. Respiratory sounds of lungs weak, with occasional fi ne moist rales. Three depressions sign positive, with no cyanosis.

Laboratory Tests By throat swabs, universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, leukocyte count 10.20 × 10 9 /L, neutrophils 93.3 %, lymphocyte 5.6 %, hemoglobin 147 g/L, CPR 47 mg/L. By blood gas analysis, pH 7.45, PaCO 2 37.2 mmHg, PaO 2 57 mmHg, Signs . Body temperature 36.9 °C, heart rate 100 beats/ min, breathing rate 22 times/min and blood pressure 118/88 mmHg. Pharynx obviously congested. The posterior wall of pharynx had follicles hyperplasia. The right tonsil swollen to II degrees. Coarse respiration sounds of both lungs. Occasional moist rales in the right lower lung with rare wheezing rales. By routine blood tests on Nov. 3rd, 2009, hemoglobin 130.3 g/L, leukocyte count 26.03 × 10 9 /L, erythrocyte count 4.67 × 10 12 /L, neutrophils 75.9 %, lymphocytes 14.30 % and mononuclear cells 7.5 %.

Diagnostic Imaging On Nov. 3rd, 2009 ( Fig. 11 .15a, b ): chest X-ray demonstrated small patchy light shadows in the right lower lung, with blurry boundaries. Enhanced and deranged pulmonary markings of both lungs. Enlarged and thickened pulmonary hili of both lungs.

On Nov. 3rd, 2009 ( Fig. 11 .15c-f ): chest CT scanning demonstrated patchy foci with high density in the right lower lung, with unclear boundaries.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests on Nov. 8th, 2009, leukocyte count 0.6 × 10 9 /L and neutrophils 30 %.

By routine blood tests on Nov. 9th, 2009, leukocyte count 1.01 × 10 9 /L, lymphocytes 73.3 % and neutro-phils13.8 %.

By routine blood tests on Nov. 10th, 2009, leukocyte count 1.06 × 10 9 /L, lymphocytes 41.5 % and neutrophils 43.4 %.

By routine blood tests on Nov. 11th, 2009, leukocyte count 1.63 × 10 9 /L, lymphocytes 49.1 % and neutrophils 35.6 %.

Blood was transfused to increase leukocyte. By routine blood tests on Nov. 12th, 2009, leukocyte count 10.93 × 10 9 /L, lymphocytes 21.3 % and neutrophils 45.4 %.

By routine blood tests on Nov. 13th, 2009, leukocyte count 14.06 × 10 9 /L, lymphocytes 15.5 % and neutrophils 62.8 %.

Diagnostic Imaging . On Nov. 10th, 2009 ( Fig. 11 .16 ): chest X-ray demonstrated blurry pulmonary marking of both lungs, small spotty shadows distributing along with pulmonary markings of both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 9-years-old boy complained of fever, cough and sore throat for 4 days. His highest body temperature 38 °C, with irregular temperature changes. Coughs paroxysmal, with more yellowish thick phlegm. Sore throat, with foreign body sensation during swallowings. The body temperature 40 °C on the next day. Past History . None related to the present illness. Contact History . He had a history of contact to fever liked cases. Several fever cases occurred in the school he was studying in and three were de fi nitively diagnosed as having In fl uenza A (H1N1).

Signs . Body temperature 36.5 °C, heart rate 120 beats/ min, breathing rate 20 times/min, blood pressure 117/73 mmHg. No lips cyanosis. Pharyngeal congestion obvious. No follicles hyperplasia on the posterior wall of pharynx. No leukoplakia. The left tonsil swollen of II degrees and the right tonsil swollen of III degrees, with no pus. No abnormalities in heart, lungs, abdomen and the nervous system. History of Present Illness . A 7-months-old boy with complaints of fever and cough for 2 days. Body temperature 39.2 °C, with coughing up phlegm and runny nose.

Past History . None related to the present illness. Contact History . He had a history of fever.

Signs . Pharyngeal congestion, with no tonsillar enlargement. Moist rale in both lungs.

Laboratory History of Present Illness . A 3-years-old boy with chief complaints of fever, cough and shortness of breath for 6 days. He suffered from fever 6 days ago, with accompanying cough, sputum and shortness of breath after activities. In the local hospital, he was diagnosed as tonsillitis and received double coptis chinensis for 1 day. He still had fever, cough, more severe shortness of breath and dyspnea. On d 6, throat swabs found In fl uenza A (H1N1) positive and the patient was transferred to You'an Hospital in Beijing. Past History . None related to the present illness. Contact History . Several children had fever in the kindergarten he was studying in.

Signs . Body temperature 39 °C, Pharyngeal congestion, with tonsils swollen to I degree. Shortness of breath, coarse respiration sound of both lungs, fi ne moist rale in the left lower lung, frequent wheezing in the right lung. Heart beats 118/min, palpable liver at 1 cm below the rib. By routine blood tests on Nov. 12th, 2009, leukocyte count 11.58 × 10 9 /L, neutrophils 71.97 % and lymphocytes 19.24 %.

By routine blood tests on Nov. 14th, 2009, leukocyte count 9.73 × 10 9 /L, neutrophils 30.64 % and lymphocytes 31.14 %.

By blood biochemistry on Nov. : chest X-ray demonstrated large fl aky blurry shadows with increased density in the right lower lung, enlarged and thickened hilum, increased and thickened pulmonary markings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Case 11.20

History of Present Illness . A 2.5-years-old boy with chief complaints of fever and cough for 8 days. He suffered from fever and cough 8 days ago. In a nearby clinic, the cephalosporin antibiotics and double coptis chinensis were administered for 2 days with no improved conditions. He had a poor appetite, aggravated cough, poor spirituality and erosive mouth corners. He was suspected as having measles and transferred to You'an Hospital in Beijing. Past History . None related to present illness. Contact History . No de fi nitive contact to In fl uenza A (H1N1) patients.

Signs . Body temperature 38.7 °C. Mouth corners erosive and scattered spotty leukoplakia on oral mucosa. The respiration sound coarse, with frequent moist rales. Heartbeat 130/min. History of Present Illness . A 14-years-old boy, complained of fever and dry cough for 1 day, with runny nose of watery rhinorrhea. Past History . None related to the present illness. Contact History . He reported a history of contacts with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion. The highest body temperature 39.2 °C. Diagnosis . Pneumonia complicating In fl uenza A (H1N1).

History of Present Illness . A 6-years-old boy with chief complaints of fever and cough with wheezing for 2 days. He also had dry cough and fatigue.

Past History . None related to the present illness. Contact History . He denied contacts with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.4 °C. Pharyngeal congestion. Tonsils swollen of II degree.

Laboratory Tests By throat swabs, universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, on Nov. 3rd, 2009, leukocyte count 3.82 × 10 9 /L, lymphocytes 46.1 % and neutrophils 23.8 %.

By liver function tests, ALT 39.6 U/L and AST 53.2 U/L.

By routine blood tests on Nov. 6th, 2009, leukocyte count 6.57 × 10 9 /L, lymphocytes 50.8 % and neutrophils 32.2 %.

By liver function tests, ALT 25.56 U/L and AST 30.2 U/L.

Diagnostic Imaging On Nov. 1st, 2009 ( Fig. 11 .21 ): chest X-ray demonstrated fl aky and fl occulent shadows in both lungs, being more obvious in the right lower lung. Pulmonary markings deranged. Pulmonary hila unclear. The chest and neck have subcutaneous gas density shadows.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 12-years-old boy, complained of cough and expectoration for 2 weeks; aggravated conditions and fever for 3 days. He also had fatigue, poor appetite, runny nose and muscle soreness. Past History . None related to the present illness. Contact History . He reported a history of contact to In fl uenza A (H1N1) patients.

Signs . Body temperature 39.8 °C. Pharyngeal congestion. Tonsils not enlarged. By routine blood tests on Oct. 30th, 2009, leukocyte count 3.8 × 10 9 /L, lymphocytes 54.1 % and neutrophils 23.4 %.

By blood gas analysis on Nov. 1st, 2009, pH 7.513, PaCO 2 34.9 mmHg, PaO 2 77.9 mmHg.

By blood gas analysis on Nov. 3rd, 2009, pH 7.46, PaCO 2 26 mmHg, PaO 2 56.9 mmHg.

By blood gas analysis on Nov. 4th, 2009, pH 7.437, PaCO 2 43.4 mmHg, PaO 2 129.7 mmHg.

By blood gas analysis, pH 7.485, PaCO 2 34.6 mmHg, PaO 2 54.8 mmHg.

Diagnostic Imaging On Oct. 30th, 2009 ( Fig. 11 .23a ): chest X-ray demonstrated multiple fl aky blurry shadows in the right lung, with enlarged and thickened hilum.

On Oct. 31st, 2009 ( Fig. 11 .23b ): chest X-ray demonstrated progressed in fl ammation in the right lung, with enlarged in fl ammatory area.

On Nov. 2nd, 2009 ( Fig. 11 .23c ): chest X-ray demonstrated enlarged in fl ammatory area.

On Nov. 4th, 2009 ( Fig. 11 .23d ): chest X-ray demonstrated enlarged foci, diffusive cloud mist liked shadows with increased density of the left lung.

On Nov. 7th, 2009 ( Fig. 11 .23e ): chest X-ray demonstrated patchy shadows in the right lung and the in fl ammation obviously absorbed.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Medical History . A 14-years-old boy, complained of fever and cough for 4 days.

On Nov. 6th, 2009, The patient fever without obvious causes, with a body temperature of 37.5 °C, which was irregular. He also had fatigue, paroxysmal cough occasionally with yellowish phlegm.

On Nov. 9th, 2009, The patient recurrent fever without obvious causes, with a body temperature of 39.0 °C. He also had chills, chest distress, dizziness, headache, general fatigue and muscle soreness. No runny nose and nasal obstruction. No chest pain, shortness of breath, palpitation, coughing up blood and dyspnea. He had a sore throat, foreign-body sensation during swallowing with accompanying nausea.

Past History . None related to the present illness. Contact History . He reported a history of contacting with suspected patients with fever and a history of contacting with In fl uenza A (H1N1) patients. The school he was studying in was an epidemic area of In fl uenza A (H1N1).

Signs . Body temperature 37.3 °C, heart rate 108 beats/ min. Breathing rate 22 times/min and blood pressure 102/63 mmHg. No lips cyanosis. Pharyngeal congestion. Follicles hyperplasia in the posterior wall of pharynx, no leukoplakia. Bilateral tonsils swollen to III degree. Respiratory sounds coarse in both lungs, with occasional fi ne dry and moist rales in both lungs. Case 11. 25 History of Present Illness . A 6.5-years-old girl, complained of fever and cough for 6 days. Past History . None related to the present illness. Contact History . Self-reports of no history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.7 °C, with pharyngeal congestion and tonsils swollen to II degree. Coarse respiration sounds of both lungs, with occasional coarse moist rales but none after cough. History of Present Illness . A 7-years-old boy, complained of fever and cough for 4 days. He coughed up a little whitish thick phlegm and occasional yellowish thick phlegm, with the fever and cough recurrent; increased and nonimproved cough and expectoration. Past History . None related to the present illness. Contact History . Self reported a history of contacting closely with suspected fever patients.

Signs . Body temperature 38.2 °C, with the highest being 39.2 °C. Breathing rate 22 times/min; heart rate 105 beats/min; blood pressure 90/62 mmHg. Pharyngeal congestion, with bilateral tonsils swollen to II degree, but no suppuration. Respiratory sound coarse of both lungs. enlarged and thickened pulmonary hila with the right hilum more obvious.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 12-years-old boy, complained of fever and cough for 5 days at clinic visit. He suffered from fever 5 days ago, with a body temperature of 39.7 °C and accompanying cough with whitish thick phlegm. No chills, convulsions, sore throat, nasal obstruction, runny nose, chest pain and diarrhea. In the local hospital, he received therapies of cefoperazone, Qingkailing, and Azithromycin for 4 days, with his body temperature still above 39 °C. At the day 5 of fever, he was found throat swabs positive and was then transferred to You'an Hospital in Beijing. Past History . Self-report of myocarditis 8 years ago, cured. And self report a history of encephalitis 4 years ago.

Contact History . Self report with a history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion, with tonsils swollen to I degree. Respiration sounds coarse of both lungs, with no moist rales.

Laboratory Tests By throat swabs, universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus positive, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests on Nov. 9th, 2009, leukocytes count 3.47 × 10 9 /L, neutrophils 24.72 %, lymphocytes 63.41 %, erythrocytes count 4.81 × 10 12 /L, hemoglobin 139 g/L and platelets count 220 × 10 9 /L.

By routine blood tests, on Nov. 14th, 2009, leukocytes count 6.55 × 10 9 /L, neutrophils 37.10 %, lymphocytes 52.81 %, erythrocytes count 4.51 × 10 12 /L, hemoglobin 131 g/L, platelets count 286 × 10 9 /L. By blood biochemistry on Nov. 9th, 2009, liver function normal, kidney function normal, electrolytes normal, ALP 400 U/L, cholinesterase normal, and myocardial enzymes normal.

All Diagnostic Imaging On Nov. 8th, 2009 ( Fig. 11 .28a ): chest X-ray demonstrated increased density shadows of the left pulmonary hilum and slightly increased cardiac shadow.

On Nov. 9th, 2009 ( Fig. 11 .28b-f ): chest CT scanning demonstrated patchy and cord liked shadows with increased density in the right upper lung and the left lung, with blurry boundaries but adhesion to pleura; no calci fi ed foci.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1).

History of Present Illness . A 2-years-old boy, with chief complaints of fever and cough for 2 days, with accompanying runny nose. No chills and fatigue. Past History . None related to the present illness. Contact History . Self-reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.6 °C, with pharyngeal congestion. Tonsils swollen to I degree.

Laboratory By routine blood tests, leukocytes count 5.9 × 10 9 /L, lymphocytes 51.6 %, neutrophils 42.6 % and platelets count 190 × 10 9 /L. Diagnostic Imaging On Oct. 14th, 2009 ( Fig. 11 .27 ): chest X-ray demonstrated diffusive patchy shadows of both lungs, with blurry pulmonary markings and the right lung more obvious.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 5-years-old boy, complained of fever and cough for 5 days and hospitalized. He suffered from fever 5 days ago, with obvious paroxysmal cough. After therapies of Cefoperazone and Azithromycin, fever did not subside with a maintained body temperature of 36.6-39.5 °C. He also had nasal obstruction and runny nose. On the day of clinic visit, the throat swabs positive.

Past History . A reported past history of bronchial pneumonia 12 days ago.

Contact History . Not reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.2 °C. Pharyngeal congestion, tonsils swollen to I degree. Respiration sounds of both lungs coarse, with occasional wheezing. Heart rate 128 beats/min. By routine blood tests on Nov. 11th, 2009, leukocytes count 6.63 × 10 9 /L, neutrophils 70.9 %, lymphocytes 20.8 %, erythrocytes count 3.7 × 10 12 /L, hemoglobin 116 g/L, platelets count 157 × 10 9 /L and CRP 1.6 mg/L.

By routine blood tests on Nov. 15th, 2009, leukocytes count 5.83 × 10 9 /L, neutrophils 19.62 %, lymphocytes 58.31 %, erythrocytes count 3.45 × 10 12 /L, hemoglobin 113 g/L and platelets count 132 × 10 9 /L. History of Present Illness . A 9-years-old boy, with chief complaints of fever, cough and expectoration for 3 days. He also suffered from chills, nasal obstruction, runny nose and slight cough with a little yellowish phlegm. Past History . None related to the present illness. Contact History . Self reported a history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 38.5 °C, with pharyngeal congestion and tonsils swollen to I degree. Respiration sound of both lungs clear. History of Present Illness . A 7-years-old boy, complained of fever and cough for 2 days, with accompanying chills, slight cough with no phlegm, no nasal obstruction and runny nose. Contact History . Self report of coming from epidemic area.

Past History . None related to the present illness.

Signs . Body temperature 39.4 °C, with pharyngeal congestion and tonsils swollen to II degree. By routine blood tests on June 7th, 2009, leukocytes count 6.92 × 10 9 /L, lymphocytes 15.7 % and neutrophils 65.4 %.

By routine blood tests on June 7th, 2009, leukocytes count 11.4 × 10 9 /L, lymphocytes 22 % and neutrophils 58 %.

By routine blood tests on June 29th, 2009, leukocytes count 5.2 × 10 9 /L, lymphocytes 23.1 % and neutrophils 57.2 %.

Diagnostic Imaging On June 28th, 2009 ( Fig. 11 .31a ): chest X-ray demonstrated large fl aky blurry shadows of middle-lateral peripheries in the right lower lung; unclearly demonstrated right lateral diaphragmatic surface and costophrenic angle. History of Present Illness . A 18-years-old man, complained of fever, cough and expectoration for 4 days, with accompanying runny nose.

Past History . None related to the present illness. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 40.1 °C, with pharyngeal congestion but no tonsils not enlarged. Moist rales of both lungs. History of Present Illness . A 16-years-old boy, complained of fever for 4 days and the right chest pain for 3 days. He also suffered from chills, runny nose, cough with whitish phlegm. Three days before hospitalized he started feeling distending and persistent right chest pain, with bloody phlegm and shortness of breath.

Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Body temperature 36.9 °C, heart rate 76 beats/ min, breathing rate 20 times/min and blood pressure 115/65 mmHg. By routine blood tests on Nov. 25th, 2009, leukocytes count 7.9 × 10 9 /L, neutrophils 82.7 % and lymphocytes 12.2 %.

By blood gas analysis, pH 7.408, PaCO 2 34.6 mmHg, PaO 2 86 mmHg, SaO 2 97 % and History of Present Illness . A 31-years-old woman, 4 days after her cesarean delivery, with chief complaints of high fever, spasmodic breathing, and progressive dyspnea for 2 days. She suffered from sudden high fever 2 days after delivery and cough 1 day ago, with pink foamy phlegm. She also had progressive dyspnea, with no improvement after therapies but rapid deterioration. Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . The highest body temperature 40 °C, with lips cyanosis. Respiration sound of both lungs coarse, with diffusive dry and moist rales. Heart rate 136 beats/min, being regular. Abdomen bloating. By routine blood tests on Nov. 8th, 2009, leukocytes count 12.97 × 10 9 /L, erythrocytes count 3.24 × 10 12 /L, hemoglobin 83 g/L, neutrophils 91.1 %, platelets count 295 × 10 9 /L.

By routine blood tests on Nov. 19th, 2009, leukocytes count 17.31 × 10 9 /L, hemoglobin 116 g/L, neutrophils 84.7 % and platelets count 257 × 10 9 /L. By blood gas analysis, albumin 31.20 g/L, creatinine 147.4 m mol/L and C-reactive protein 163 mg/L.

Diagnostic Imaging On Nov. 6th, 2009 ( Fig. 11.34a,  b ) : chest X-ray demonstrated large fl aky blurry shadows with increased density in both lungs.

On Nov. 6th, 2009 ( Fig. 11 .34c-s ): chest CT scanning demonstrated large fl aky blurry shadows with increased density in the posterior basal segments of both lower lungs; parenchymal changes of some pulmonary tissues; enlarged and thickened pulmonary hila.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 27-years-old woman, complained of menopause for 37 +5 weeks and fever for 7 days. She also complained of frequent fetal movements for 5 days, decreased fetal movements for 1 day and bloody show for 2 days. Symptoms also included fever 7 days ago, with throat upset, general soreness and the highest body temperature 39.5 °C. Six days ago she suffered from frequent cough, a sore throat, dif fi culty supine and body temperatures fl uctuating between 38 and 39.5 °C. She was admitted on Nov. 14th, 2009. Medical consultation made a decision of terminating pregnancy.

Diagnosis . Pregnancy for 37 +5 weeks, In fl uenza A (H1N1), pneumonia, suspected respiratory failure, fatal distress and anemia.

Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Body height 164 cm, weight 80 kg, uterus height 31 cm, abdominal girth 93 cm and estimated fetus weight 3,300 g. Position of fetal heart LOA, fatal heart rate regular about 146 beats/min. Presentation fl oating, no palpable uterine contraction. External pelvimeters IS 24 cm, IC 26 cm, EC 19 cm and TO 9 cm.

By obstetrical color ultrasonography on Nov. 14th, 2009, static fetal heartbeat. By routine blood tests on Nov. 14th, 2009, leukocytes count 5.25 × 10 9 /L, hemoglobin 86 g/L, neutrophils 82.1 %, lymphocytes 16.4 %, platelets count 174 × 10 9 /L, albumin 16 g/L and globulin 22.47 g/L.

By blood gas analysis on Nov. 14th, 2009, pH 7.42, PaCO 2 19.13 mmHg, PaO 2 63 mmHg and oxygen saturation 95 %.

By routine blood tests, leukocytes count 7.09 × 10 9 /L, hemoglobin 105 g/L, neutrophils 73.3 %, lymphocytes 19.7 % and platelets count 418 × 10 9 /L. By blood biochemistry, albumin 32.88 g/L and creatinine 60.6 m mol/L.

Diagnostic Imaging On Nov. 23rd, 2009 ( Fig. 11.35a ) : chest X-ray demonstrated diffusive blurry shadows with increased density in the right lower lung; cloud mist liked shadows with increased density in the left lower lung; enlarged and thickened pulmonary hilum.

On Nov. 25th, 2009 ( Fig. 11 .35b ): chest X-ray demonstrated diffusive cloudy shadows with increased density in the right lower lung; enlarged and thickened pulmonary hilum; no improvements compared to the previous imaging results.

On Nov. 25th, 2009 ( Fig. 11 .35c-p ): CT scanning demonstrated large fl aky dense shadows in the right lower lung.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports History of Present Illness . A 24-years-old woman, complained of cough, expectoration and fever for 3 days, with the highest body temperature 39.8 °C, yellowish mucoid phlegm and spontaneous sweating. Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Respiration sounds of both lungs coarse, with moist rale in both lower lungs. Heart beats 108 beats/ min.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus negative, the universal gene (NP gene) of H1N1 swine fl u virus negative, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood Tests, leukocytes count 11.08 × 10 9 /L, hemoglobin 77 g/L, neutrophils 91.9 %, C-reactive protein 45.5 mg/L, total protein 57.48 g/L and albumin 26.42 g/L.

By routine blood tests on Nov. 25th, 2009, leukocytes 12.99 × 10 9 /L, erythrocytes count 3.85 × 10 12 /L, hemoglobin 100 g/L, neutrophils 88.3 %, platelets count 158 × 10 9 /L and albumin 28.34 g/L.

Diagnostic Imaging On Nov. 3rd, 2009 ( Fig. 11 .36a, b ): chest X-ray demonstrated fl aky cloudy shadow with increased density in both lower lungs; enlarged and thickened pulmonary hilum.

On Nov. 5th, 2009 ( Fig. 11.36c ) : chest X-ray demonstrated diffusive fl aky cloudy shadow with increased density in middle-lower lobes of both lungs, thickened hilum covered; obvious progression compared to previous chest X-ray.

On Nov. 6th, 2009 ( Fig. 11 .36d ): chest X-ray demonstrated diffusive fl aky cloudy shadow with increased density in middle-lower lobes of both lungs; thickened hilum covered; no obvious changes compared to the previous chest X-ray.

On Nov. 7th, 2009 ( Fig. 11 .36e ): chest X-ray demonstrated diffusive fl aky cloudy shadows with increased density in middle-lower lobes of both lungs; thickened hilum covered; no obvious changed compared to the previous chest X-ray.

On Nov. 7th, 2009 ( Fig. 11 .36f-l ): chest CT scanning demonstrated diffusive patchy parenchymal shadows with increased density in both lungs, with air bronchogram.

On Nov. 23rd, 2009 ( Fig. 11 .36m ): chest X-ray demonstrated diffusive fl aky cloudy shadows with increased density in both lungs; thickened hilum covered; obvious progression compared to previous X-ray.

On Nov. 23rd, 2009 ( Fig. 11 .36n-x ): chest CT scanning demonstrated diffusive parenchymal shadows with increased density and ground glass-like shadows in both lungs, with gas bronchogram which was more obvious in the posterior basal segments of both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports History of Present Illness . A 18-years-old woman, with chief complaints of fever and cough for 2 days, with dyspnea and vomiting for 1 day. Hospitalized. Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion, with antiadoncus. Moist rales in both lungs and respiration sound coarse.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus negative, the universal gene (NP gene) of H1N1 swine fl u virus negative, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, leukocytes count 11.1 × 10 9 /L and neutrophils 82 %.

By blood gas analysis, pH 7.43, PaCO 2 35.2 mmHg, PaO 2 66 mmHg, History of Present Illness . A 19-years-old woman, complained of fever, cough and a sore throat for 26 h. Past History . None related to the present illness. Contact History . Self reported history of contacting closely with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.7 °C, with pharyngeal congestion.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus negative, the universal gene (NP gene) of H1N1 swine fl u virus negative, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

On Nov. 23rd, 2009, By routine blood tests, leukocytes count 8.77 × 10 9 /L, neutrophils 81.6 % and lymphocytes 9.6 %.

By blood gas analysis, ALT 13.5 U/L and AST 21.4 U/L. By routine blood tests on Nov. 24th, 2009, leukocytes count 5.41 × 10 9 /L, neutrophils 62.74 % and lymphocytes 27.50 %.

Diagnostic Imaging On Nov. 25th, 2009 ( Fig. 11 .38a-d ): chest plain CT scanning demonstrated large fl aky shadows with increased density in the right middle lung.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Acute facial features. History of Present Illness . A 23-years-old man, complained of fever, cough and expectoration for a week, with a body temperature of 39 °C and no chills and chest distress.

Past History . None related to the present illness. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion, with tonsils not enlarged.

Laboratory Tests Throat swabs by CDC found universal gene (M gene) of in fl uenza A virus positive, the universal gene (NP gene) of H1N1 swine fl u virus negative, speci fi c gene (HA gene) of In fl uenza A (H1N1) virus positive.

By routine blood tests, leukocytes count 1.48 × 10 9 /L, hemoglobin 130 g/L, platelets count 130 × 10 12 /L.

By routine blood tests on Nov. 14th, 2009, leukocytes count 2.39 × 10 9 /L, lymphocytes 36.4 % and neutrophils 51.1 %.

By blood gas analysis, pH 7.462, PaCO 2 40.1 mmHg and PaO 2 79.2 mmHg.

Diagnostic Imaging On Nov. 14th, 2009 ( Fig. 11.39a ) : chest X-ray demonstrated patchy fl occulent shadows in lower lobes of both lungs; enhanced Lung markings.

On Nov. 15th, 2009 ( Fig. 11 .39b ): chest X-ray demonstrated fl aky cloudy shadows with increased density in lower lobes of both lungs; thickened lung markings and enlarged left lung hilum; obvious improved conditions compared to previous chest X-ray.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests leukocytes count 8.28 × 10 9 /L, lymphocytes 10.1 % and neutrophils 78.5 %.

Diagnostic Imaging On Nov. 11th, 2009 ( Fig. 11.40a ) : chest X-ray demonstrated symmetrical thorax; rightward migration of the trachea; decreased transparency of both lungs fi elds; enhanced and blurry lung markings; multiple intrapulmonary patchy blurry shadows, and heart shadow enlarged.

On Nov. 13th, 2009 ( Fig. 11 .40b ): chest X-ray demonstrated symmetrical thorax, rightward migration of the trachea, decreased transparency of both lungs, thickened lung markings, multiple intrapulmonary fl occulent patchy shadows in both lungs.

On Nov. 15th, 2009 ( Fig. 11.40c ) : chest X-ray demonstrated enhanced and blurry lung markings, multiple intrapulmonary patchy cloudy shadows, and cardiac shadow enlarged.

On Nov. 17th, 2009 ( Fig. 11 .40d ): chest X-ray demonstrated enhanced and blurry lung markings, decreased transparency of both lungs, multiple intrapulmonary patchy cloudy shadows, and the cardiac shadow enlarged.

On Nov. 20th, 2009 ( Fig. 11 .40e ): chest X-ray demonstrated blurry lung markings, multiple intrapulmonary patchy blurry shadows; decreased shadows in the right lung compared to the previous X-ray.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 21-years-old man, complained of fever for 5 days and cough for 1 day. He also suffered from headache, throat itch, nasal obstruction and runny nose. Past History . None related to the present illness. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 37.8 °C, with pharyngeal congestion and tonsils swollen to I degree.

Laboratory On Nov. 12th, 2009, ECG normal. On Nov. 13th, 2009, sputum culture negative. By routine blood tests on Nov. 17th, 2009, leukocytes count 11.31 × 10 9 /L, neutrophils 68.3 %, lymphocytes 21.6 % and erythrocytes count 4.72 × 10 12 /L. On Nov. 18th, 2009, the patients was cured to be discharged.

Diagnostic Imaging On Nov. 10th, 2009 (Fig. 11.41a ) : chest X-ray demonstrated fl aky blurry shadows of the right middle-upper lung, enlarged and thickened pulmonary hilum, increased and thickened lung markings.

On Nov. 10th, 2009 (Fig. 11 .41b-i ): chest CT scanning demonstrated patchy light blurry shadows and ground glass liked shadows in bilateral lower lungs and the right middle lung, with uneven densities; no other abnormalities.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 42-years-old man, with chief complaints of fever and cough for 5 days. Past History . Self reported history of Hepatitis B for 10 years with regular liver function examination every half a year. None recent abnormalities.

Contact History . He denied recent contacts with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.5 °C, with pharyngeal congestion and tonsils swollen to I degree. Coarse respiration sounds of bilateral lungs.

Laboratory By HBV-DNA, 2.54 × 10 3 . By physical examinations on Nov. 8th, 2009, persistent fever during hospitalization, with body temperatures between 37.4 and 39.2 °C. The patient also had cough, expectoration and chest distress. Moist rales in both lungs and the right lung extensive moist rales.

By routine blood tests on Nov. 9th, 2009, leukocytes count 11.47 × 10 9 /L, neutrophils 81.03 % and lymphocytes 8.82 %.

By blood biochemistry on Nov. 9th, 2009, TP 55 g/L, A 24 g/L, AST 64 U/L, ALT 54 U/L and BUN 3.4 mmol/L. By blood gas analysis on Nov. 10th, 2009, pH 7.517, PaCO 2 33.3 mmHg, PaO 2 49 mmHg and SaPaO 2 91 %. The patient had progressive conditions, with palpitation, more serious chest distress, cough and obvious expectoration. His family members requested transferring into another hospital due to his deteriorating conditions. By sputum culture on Nov. 13th, 2009, Candida albicans positive.

On Nov. 4th, 2009, ECG normal. Diagnostic Imaging By B-mode ultrasonography on Nov. 7th, 2009, diffusive echo of liver parenchymal changes; multiple intrahepatic cysts in liver; hemangioma in right lobe of liver; spleen thickness 45 mm.

By chest CT scanning on Nov. 5th, 2009 ( Fig. 11 .42a-g ), decreased transparency of the right lung with large fl aky shadows; small fl aky shadows in the left lower lung next to the heart margin with air bronchogram.

By chest X-ray on Nov. 5th, 2009 (Fig. 11.42h ) , large fl aky cloud mist liked blurry shadows of both lungs; parenchymal changes shadows of the right upper lung.

By chest CT scanning on Nov. 9th, 2009 ( Fig. 11.42i-q ) , scattered fl occulent light blurry shadows and ground glass liked shadows in both lungs; parenchymal changes of partial lung tissues; gas bronchogram and quite good transparency of the left lung.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 41-years-old woman, complained of fever and cough for 6 days, with accompanying headache, runny nose, no phlegm, no chills and no fatigue. Past History . None related to the present illness. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.3 °C, with pharyngeal congestion and tonsils swollen to II degree.

Laboratory By routine blood tests, leukocytes count 2.5 × 10 9 /L, lymphocytes 26.8 % and neutrophils 65.6 %.

Diagnostic Imaging By chest X-ray on Nov. 17th, 2009 (Fig. 11.43a ) : thickened lung markings of both lower lungs, with spotty blurry shadows.

By chest CT scanning on Nov. 18th, 2009 (Fig. 11 .43bp ): multiple patchy shadows in dorsal segment of the left lower lung and posterior basal segment of the right lower lung, with blurry boundaries.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 37-years-old man, with chief complaints of fever and cough for 1 week, with expectoration of a little whitish phlegm, chest distress and progressively deteriorated conditions. By blood gas analysis, type I respiratory failure. After hospitalized, he was masked for inhalation of oxygen. Past History . None related to the present illness. Contact History . Self reported recent contacts with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C, with pharyngeal congestion and tonsils not enlarged. Moist rales of both lungs.

Laboratory Diagnostic Imaging By chest X-ray on Nov. 14th, 2009 (Fig. 11.45 ): fl occulent patchy cloudy shadows with high density in both lungs, more obvious in the lower lobes; blurry lung markings; enlarged and blurry hila.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). On Nov. 21st, 2009, suddenly slowed heart rate, decreased blood pressure and reduced arterial oxygen saturation to 35 %. Death occurred during emergency rescuing.

Laboratory By routine blood tests on Nov. 21st, 2009, leukocytes count 3.5 × 10 9 /L, neutrophils 83.6 %, band neutrophils 8-14 %, with visible toxic granules.

By liver functions test, ALT 33.9 U/L with the highest of 109 U/L, AST 85.8 U/L with the highest of 507 U/L. By renal functions test, BUN and Cr normal.

Diagnostic Imaging By chest X-ray on Nov. 20th, 2009 (Fig. 11.44 ): large blurry shadows with increased density in middle and lower lobes of both lungs, more obvious in the both lower lungs; unclearly de fi ned costophrenic angle at the uppermost of diaphragm.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 19-years-old man, complained of fever, headache and cough for 1 day, with irregular fever, headache, dizziness, cough and fatigue. He also suffered from a sore throat and a foreign-body sensation when swallowing. The next day, his body temperature reached 38.5 °C, with cough of a little yellowish and whitish phlegm. By physical examinations, hemogram increased, high body temperature of 42 °C, with nausea, vomiting, chest distress and shortness of breath. Past History . None related to the present illness. Contact History . Self reported contacts with suspected fever patients. The school he was studying in had many students suffering from fever and four were de fi nitively diagnosed as In fl uenza A (H1N1) patients.

Signs . Body temperature 39.8 °C. Heart rate 102 beats/ min, breathing rate 28 times/min and blood pressure By routine blood tests on Nov. 8th, 2009, hemoglobin 135 g/L, WBC 5.50 × 10 9 /L, platelets count 175 × 10 9 /L and neutrophils 70.7 %.

Diagnostic Imaging By chest X-ray on Nov. 8th, 2009 (Fig. 11.46a ) : coarse lung markings of both lower lungs, enlarged pulmonary hila.

By chest CT scanning on Nov. 8th, 2009 (Fig. 11 .46be ) cloud mist liked blurry shadows of both lower lungs, decreased transparency of both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 44-years-old man, was hospitalized due to cough and expectoration for 6 days and fever for 4 days. One week prior to hospitalization, he accompanied a guest to the airport and no other reported contact histories. Past History . Self reported history of diabetes for 2 years.

Contact History . Denied.

Signs . Body temperature 36 °C. Coarse respiration sound of bilateral lungs.

Laboratory Tests By throat swabs, PT-PCR test positive for the nucleic acid of In fl uenza A (H1N1) virus.

By routine blood Tests, hemoglobin 135 g/L, leukocytes count 5.1 × 10 9 /L, neutrophils 52.1 % and lymphocytes 32.3 %.

Diagnostic Imaging By chest X-ray on Nov. 14th, 2009 ( Fig. 11 .47a ): enhanced lung markings of both lungs; small fl aky shadows with increased density in the middle band of the right upper lung, with a cord liked shadow connecting to the pulmonary hilum; irregular grid liked and spotty fl aky shadows with densed density in the middle and lower right lung, unclear boundaries.

By X-ray on Nov. 16th, 2009 (Fig. 11 .47b ): enhanced lung markings of both lungs; scattered spotty and fl aky shadows with densed density and irregular grid liked shadows in the both middle and lower lungs, boundaries unclear. Basically absorbed foci in the right upper lung, smaller focal areas in both middle and lower lungs, and less densed shadows, comparing to the previous X-ray fi ndings.

By X-ray on Nov. 18th, 2009 (Fig. 11.47c ): enhanced and blurry lung markings; intrapulmonary foci absorbed comparing to the previous X-ray fi ndings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests on June 28th, 2009, leukocytes count 5.9 × 10 9 /L, lymphocytes 16.7 % and neutrophils 70.4 %.

By routine blood tests on June 30th, 2009, leukocytes count 4.1 × 10 9 /L, lymphocytes 42.7 % and neutrophils 44.9 %.

Diagnostic Imaging By chest X-ray on June 28th, 2009 ( Fig. 11 .48 ): blurry lung markings, with accompanying patchy shadows.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 27-years-old man, complained of fever and cough for a week. His body temperature 42 °C, with chills, watery rhinorrhea, nasal obstruction and a sore throat.

Past History . Not reported. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion and tonsils swollen to I degree.

Laboratory By routine blood tests, leukocytes count 5.12 × 10 9 /L, lymphocytes 21.7 % and neutrophils 60 %.

By liver functions test, ALT 138.5 U/L and AST 53.4 U/L.

By routine blood tests on Nov. 12th, 2009, leukocytes count 10.7 × 10 9 /L, lymphocytes 6.8 % and neutrophils 87.3 %.

Diagnostic Imaging By chest X-ray on Nov. 6th, 2009 ( Fig. 11.49a History of Present Illness . A 46-years-old man, complained of fever and cough for a week. His body temperatures were interictal, with the highest body temperature of 40.33 °C. He also suffered from chills, a sore throat, cough up a little whitish phlegm and headache. Past History . Not reported. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion, with tonsils not swollen. Moist rales of both lungs.

Laboratory ECG . On Nov. 6th, 2009, sinus bradycardia.

Diagnostic Imaging By chest X-ray on Nov. 6th, 2009 (Fig. 11.50a ) : increased lung markings of both lungs; multiple fl aky blurry shadows in the right lung; blurry lung markings of the left lower lung.

By chest X-ray on Nov. 8th, 2009 (Fig. 11 .50b ): increased lung markings of both lungs; multiple fl aky blurry shadows in the right lung; blurry lung markings of the left lower lung; no obvious changes compared to the previous X-ray fi ndings.

By chest X-ray on Nov. 11th, 2009 (Fig. 11.50c ): increased lung markings of both lungs; multiple fl aky blurry shadows of the right lung; improved conditions compared to the previous X-ray fi ndings.

By chest X-ray on Nov. 14th, 2009 (Fig. 11 .50d ): increased lung markings of both lungs, with spotty shadows; improved conditions compared to the previous X-ray fi ndings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). a b c d Fig. 11 .50

History of Present Illness . A 15-years-old girl, with chief complaints of recurrent fever and cough for 1 week. On Oct. 31st, 2009, she began to have fever with no obvious known causes, body temperature 38.6 °C. Her fever was irregular, with paroxysmal cough and a little whitish phlegm. She also suffered from dizziness, fatigue, rhinorrhea, nasal obstruction, a sore throat and a foreign-body sensation when swallowing. She took medicine for the cold such as Radix Isatidis, but the condition not improved. On the second day after medication, she still had dizziness and fever, with self reported body temperature of 39.2 °C. The symptoms also included chills, nausea, vomiting of saliva and deteriorated cough with a little yellowish phlegm.

Past History . Not reported. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 38.5 °C, heart rate 115 beats/ min, breathing rate 22 times/min, and blood pressure 122/65 mmHg. Pharyngeal congestion slight, no retropharyngeal folliculosis. Respiration sound coarse in both lungs, with occasional moist rales in the left lower lung. The right lung no abnormal fi ndings.

Laboratory Routine blood tests on Nov. 6th, 2009, hemoglobin 120 g/L, leukocytes count 6.18 × 10 9 /L, platelets count 119 × 10 9 /L and neutrophils 63.6 %.

By blood gas analysis on Nov. 6th, 2009, pH 7.327, PaO 2 76 mmHg, PaCO 2 38.6 mmHg and oxygen content 137 mL/L. By blood biochemistry on Nov. 6th, 2009, AST 38 U/L, CK 130 U/L, CK-MB 7.5 U/L, LDH 270 U/L and HBD 198 U/L.

Diagnostic Imaging By chest X-ray on Nov. 6th, 2009 (Fig. 11.51a ): cloud mist liked blurry shadows in the left lower lung.

By chest X-ray on Nov. 7th, 2009 (Fig. 11 .51b ): cloud mist liked blurry shadows in the left lower lung; increased pulmonary hilum; no obvious changes compared to the previous X-ray fi ndings.

By chest X-ray on Nov. 8th, 2009 ( Fig. 11 .51c ): cloud mist liked blurry shadows in the left lower lung; increased pulmonary hilum; no obvious changes compared to the previous X-ray fi ndings.

By chest CT scanning on Nov. 8th, 2009 ( Fig. 11 .51df ): irregular fl aky shadows with increased density in basilar segment of the left lower lung, in a size of 5 cm × 7 cm and no space occupying effect.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 18-years-old man, complained of fever for 3 days and cough for 2 days. His highest body temperature 38.5 °C, with accompanying headache, muscle soreness, slight cough and expectoration of a little yellowish thick phlegm. Past History . Not reported. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion, tonsils not swollen. Moist rales in both lungs. History of Present Illness . A 51-years-old woman, complained of fever and cough for 3 days and chest distress for 1 day. Her highest body temperature 39.7 °C, with accompanying chills, runny nose, shortness of breath and expectoration of a little odorless whitish phlegm occasionally with blood in it. Past History . Not reported. Contact History . The patients had a foreign nationality, with a self reported history of contacting with fever patients.

Signs . Pharyngeal congestion and tonsils swollen to I degree. Moist rale in both lungs.

Laboratory By blood gas analysis, pH 7.4, PaCO 2 39 mmHg and PaO 2 42.2 mmHg.

By routine blood tests, leukocytes count 6.0 × 10 9 /L and neutrophils 64 %.

By blood gas analysis on Nov. 23rd, 2009, pH 7.43, PaCO 2 41 mmHg and PaO 2 65 mmHg.

By routine blood tests, leukocytes count 3.83 × 10 9 /L and neutrophils 64 %.

By liver functions test, ALT 28.9 U/L and AST 66.7 U/L. By blood gas analysis on Nov. 24th, 2009, pH 7.4, PaCO 2 40 mmHg and PaO 2 75 mmHg.

By routine blood tests, leukocytes count 9.86 × 10 9 /L and neutrophils 72.8 %.

By liver functions test, ALT 33 U/L and AST 52 U/L. Diagnostic Imaging By chest X-ray on Nov. 22nd, 2009 (Fig. 11.53a ) : increased lung markings of both lungs; patchy shadows with high density in the right lung and the left middle and lower lung, with boundaries unclear; pulmonary hila of both lungs unclear; two costophrenic angles blur.

By chest X-ray on Nov. 24th, 2009 (Fig. 11.53b ): multiple patchy shadows in both lower lungs; progressive conditions compared to the previous chest X-ray fi ndings.

By chest X-ray on Nov. 26th, 2009 ( Fig. 11 .53c ): diffusive shadows with increased density in both lungs; decreased transparency of both lungs; progressive conditions compared to the previous chest X-ray fi ndings.

By chest X-ray on Nov. 28th, 2009 ( Fig. 11 .53d ): scattered patchy cloudy shadows with increased density in both lungs; enlarged and thickened pulmonary hilum; blunt right costophrenic angle; improved conditions compared to the previous chest X-ray fi ndings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 15-years-old boy, complained of fever and cough for 3 days. His temperatures were irregular, the highest 39.7 °C, with accompanying paroxysmal coughs, a little whitish phlegm, a sore throat and a foreign-body sensation when swallowing. Past History . Self reported frequent occurrence of the cold since childhood and persistent chronic cough and expectoration, which had been diagnosed as bronchiectasis in another hospital (no more details).

Contact History . Recent occurrence of fever in several classmates, who received no tests for In fl uenza A (H1N1). Self reported history of closely contacting with the classmates who had fever.

Signs . Body temperature 39.5 °C, heart rate 110 beats/ min, breathing rate 22 times/min and blood pressure 110/60 mmHg. Pharyngeal congestion with tonsils swollen to II degree. Vocal fremitus in both lungs weakened and respiration sound of both lungs coarse, with scattered middle and fi ne moist rales in both middle-lower lungs. Apical impulse at the midclavicular line 0.5 cm inner to the fi fth rib. Puf fi ng murmurs of 3/6 grades during systoles in apical area.

Laboratory Tests Throat swabs by CDC on Nov. 8th, 2009, nucleic acid of In fl uenza A (H1N1) virus positive.

By routine blood tests, leukocytes count 6.5 × 10 9 /L, neutrophils 80.4 %, erythrocytes count 5.86 × 10 12 /L, hemoglobin 119.4 g/L, platelets count 160 × 10 9 /L. Myocardial enzyme spectrum of CK 247 U/L, CK-MB 11.7 U/L, LDH normal, troponin I normal and aspartic acid aminotransferase normal.

By routine blood tests on Nov. 9th, 2009, leukocytes count 3.15 × 10 9 /L, neutrophils 49.6 %, erythrocytes count 6.49 × 10 12 /L, hemoglobin 125.5 g/L and platelets count 217 × 10 9 /L. Myocardial enzyme spectrum of CK 231 U/L, CK-MB 12.16 U/L, LDH normal, troponin I normal and aspartic acid aminotransferase normal.

By blood gas analysis, pH 7.452, PaCO 2 27.4 mmHg, PaO 2 75.9 mmHg, AB 18.7 mmHg and BE 5.30 mmol/L. By electrocardiography, sinus rhythm and sinus arrhythmia.

By routine blood tests on Nov. 13th, 2009, leukocytes count 4.41 × 10 9 /L and neutrophils 40.70 %.

Throat swabs by CDC on Nov. 17th, 2009, nucleic acid of In fl uenza A (H1N1) virus negative; the patient cured.

Diagnostic Imaging By chest X-ray on Nov. 8th, 2009 (Fig. 11.54a ) , lung markings increased and rough; scattered fl aky shadows with blurry boundaries and increased density in both lower lungs; thickened and enlarged hilar shadow in the right lung; decreased transparency of both lungs.

By chest CT scanning on Nov. 8th, 2009 (Fig. 11 .54b-f ), patchy lesion with high density in the left lower lung, with unclear boundaries; increased and deranged lung markings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Diagnostic Imaging By chest X-ray on Nov. 15th, 2009 (Fig. 11.55a ) , cloud mist liked blurry shadows with increased density in both lungs; parenchymal changes of partial pulmonary tissues; enlarged and thickened pulmonary hila.

By chest CT scanning on Nov. 15th, 2009 (Fig. 11 .55b-f ), large fl aky dense blurry shadows with increased density in both lungs; parenchymal changes of partial pulmonary tissues; enlarged and thickened pulmonary hila.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By blood gas analysis on Nov. 14th, 2009, pH 7.463, PaCO 2 34.6 mmHg and PaO 2 73.8 mmHg.

By blood gas analysis on Nov. 15th, 2009, pH 7.513, PaCO 2 29.1 mmHg, PaO 2 101.2 mmHg.

By routine blood tests, leukocytes count 3.76 × 10 9 /L, lymphocytes 20.7 % and neutrophils 77.4 %.

Diagnostic Imaging By chest X-ray on Nov. 7th, 2009 ( Fig. 11.56a ), thickened and deranged pulmonary markings of both lungs; multiple fl aky shadows in both lungs, with blurry boundaries; enlarged and blurry hilar shadows of both lungs.

By chest X-ray on Nov. 10th, 2009 (Fig. 11 .56b ), multiple fl aky shadows of both lungs; progressive conditions of enlarged focal area compared to the previous X-ray fi ndings on Nov. 7th, 2009.

By chest X-ray on Nov. 11th, 2009 ( Fig. 11 .56c ), multiple fl aky shadows in both lungs; improved conditions of decreased focal area compared to previous chest X-ray fi ndings on Nov. 10th, 2009.

By chest X-ray on Nov. 13th, 2009 (Fig. 11 .56d ), no obvious changes compared to previous chest X-ray fi ndings on Nov. 10th, 2009.

By chest X-ray on Nov. 15th, 2009 (Fig. 11 .56e ), improved conditions compared to the chest X-ray on Nov. 13th, 2009.

By chest X-ray on Nov. 16th, 2009 (Fig. 11 .56f ), no obvious changes compared to chest fi lm on Nov. 15th, 2009.

By chest X-ray on Nov. 18th, 2009 ( Fig. 11 .56g ), in fl ammation of both lungs; no obvious changes compared to chest X-ray fi ndings on Nov. 16th, 2009.

By chest X-ray on Nov. 20th, 2009 ( Fig. 11 .55h ), improved conditions compared to chest X-ray fi ndings on Nov. 18th, 2009. By chest CT scanning on Nov. 20th, 2009 (Fig. 11 .56i-n ), intrapulmonary patchy fl occulent shadows in both lungs, with increased density and limited foci; improved transparency of the left lower lung. Diagnosis .

Pneumonia complicating In fl uenza A (H1N1). By routine blood tests, leukocytes count 3.3 × 10 9 /L, lymphocytes 4.8 % and neutrophils 90.6 %.

Diagnostic Imaging By chest X-ray on Nov. 18th, 2009 (Fig. 11.57a ), thick and deranged lung markings of both lungs; scattered patchy blurry shadows.

By chest X-ray on Nov. 20th, 2009 (Fig. 11.57b ) , patchy cloudy shadows of both lungs; improved conditions compared to chest X-ray fi ndings on Nov. 18th, 2009.

By chest X-ray on Nov. 30th, 2009 (Fig. 11.57c ) , patchy cloudy shadows in both lungs; improved conditions compared to chest X-ray fi ndings on Nov. 20th, 2009. By chest CT scanning on Nov. 18th, 2009 (Fig. 11.57d-y ) , multiple patchy shadows in both lungs, especially in basal segments; boundaries unclear; air bronchogram.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By blood gas analysis, pH 7.397, PaCO 2 23.7 mmHg, PaO 2 107 mmHg and SaO 2 297.7 %.

By routine blood tests, leukocytes count 11.2 × 10 9 /L and neutrophils 96.3 %.

Diagnostic Imaging By chest X-ray on Nov. 19th, 2009 (Fig. 11.58 ) , fl occulent fl aky shadows in middle and lower lobes of both lungs, thickened lung markings.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 27-years-old man complained of fever, cough and expectoration for a week, with accompanying chills, shivers, rhinorrhea and nasal obstruction. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.5 °C; Pharyngeal congestion and no antiadoncus; moist rales of both lungs. Diagnostic Imaging By chest X-ray on Nov. 20th, 2009 (Fig. 11.59a ) , increased lung markings accompanied with patchy fl occulent cloudy shadows in both lower lungs; enlarged and thickened pulmonary hilum.

By chest X-ray on Nov. 22nd, 2009 (Fig. 11.59b ) , thickened lung markings of both lungs; multiple patchy fl occulent shadows in both lungs, with blurry boundaries; hilum structure unclear; the right costophrenic angle blunt; progressive conditions compared to chest X-ray fi ndings on Nov. 20th, 2009.

By chest X-ray on Nov. 24th, 2009 (Fig. 11.59c ) , increased lung markings of both lungs; spotty patchy cloudy shadows in both lungs; obviously improved conditions compared to chest X-ray fi ndings on Nov. 22nd,

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). a b Fig. 11 .59

History of Present Illness . A 25-years-old man, complained of cough for 7 days and fever for 6 days. He had no chills, but a sore throat, shortness of breath and headache, followed by spasmodic breathing, with pink foamlike phlegm. Past History . None. Contact History . Denied a history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 40 °C, with pharyngeal congestion and tonsils swollen. Moist rales in both lungs.

Laboratory By blood gas analysis, pH 7.33, PaCO 2 54 mmHg and PaO 2 85 mmHg.

By routine blood tests, leukocytes count 17.89 × 10 9 /L, lymphocytes 5.5 % and neutrophils 90.7 %.

By routine blood tests on Nov. 30th, 2009, leukocytes count 7.8 × 10 9 /L, neutrophils 88.4 % and lymphocytes 8.2 %.

By blood gas analysis, pH 7.512, PaO 2 48.8 mmHg and PaCO 2 32.16 mmHg.

By liver function tests, ALT 166.8 U/L and AST 270.5 U/L.

Diagnostic Imaging By chest X-ray on Nov. 19th, 2009( Fig. 11.60a ) , multiple fl aky cloudy shadows in both middle-lower lungs; enlarged and blurry lung hilum; costophrenic angle unclear.

By chest X-ray on Nov. 20th, 2009 (Fig. 11.60b ) , multiple fl aky cloudy shadows in both middle-lower lungs; enlarged and blurry lung hilum; improved conditions compared to chest X-ray on Nov. 19th, 2009.

By chest X-ray on Nov. 23rd, 2009 (Fig. 11.60c ) , multiple fl aky cloudy shadows in both middle-lower lungs; enlarged and parenchymal changes of lung hilum; progressive conditions compared to chest X-ray on Nov. 19th, 2009. By chest X-ray on Nov. 24th, 2009 (Fig. 11.60d ) , large fl aky cloudy shadows in both lungs; obviously deteriorated conditions compared to chest X-ray fi ndings on Nov. 23rd, 2009.

By chest X-ray on Nov. 25th, 2009 (Fig. 11.60e ) , fl aky fl occulent cloudy shadows in both lungs; increased transparency of both lungs compared to chest X-ray fi ndings on Nov. 23rd, 2009, obviously improved condones. Figure 11 .60f-g : By H&E staining, widened space between alveolar walls; Alveolar wall congestion; neutrophils and plasmacyte in fi ltrated, dominantly monocytes; alveolar edema fl uid and fi brin exudated. Figure 11 .60h-i : By H&E staining, many in fl ammatory cells in the space between cardiac muscle tissues.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 38-years-old man, complained of fever for 3 days and spasmodic breathing for 1 day. He initially had chills, fatigue, dizziness and cough; no sore throat and runny nose; followed by spasmodic breathing and dyspnea. Blood gas analysis indicated type I respiratory failure and metabolic acidosis. Past History . Histories of myocarditis, hypertension, cardiac failure.

Contact History . Self reported history of contacting with a patient with fever who was receiving vaccines for In fl uenza A (H1N1).

Signs . Body temperature 39.6 °C; blood pressure 75/58 mmHg.

Laboratory By routine blood tests on Oct. 29th, 2009, leukocytes count 6.64 × 10 9 /L, neutrophils 89.8 % and lymphocytes 6.0 %.

By blood gas analysis: pH 7.423, PaO 2 78.4 mmHg and PaCO 2 37.2 mmHg.

By liver function tests on Oct. 30th, 2009, ALT 187.2 U/L and AST 148.2 U/L.

Diagnostic Imaging By chest X-ray on Oct. 28th, 2009 (Fig. 11.61a ) : multiple fl aky fl occulent cloudy shadows in both lungs, more obvious in both middle-lower lungs; hilum structure of both lungs blurry.

By chest X-ray on Oct. 30th, 2009 (Fig. 11.61b ): multiple fl aky fl occulent cloudy shadows in both middlelower lungs; some foci absorbed and improved conditions compared to chest X-ray fi ndings on Oct. 28th, 2009.

By chest X-ray on Nov. 2nd, 2009 (Fig. 11.61c Contact History . In the school he was studying in, many students had fever and some was diagnosed as In fl uenza A (H1N1). Self reported history of contacting with patients de fi nitively diagnosed as In fl uenza A (H1N1).

Signs . Body temperature 39.1 °C; heart rate 133 beats/ min, breathing rate 24 times/min and blood pressure 95/54 mmHg. He was conscious, but with slight shortness of breath. Pharyngeal congestion obvious. No retropharyngeal folliculosis. Bilateral tonsils swollen to II degree.

Laboratory By routine blood tests, hemoglobin 153 g/L, leukocytes count 10.41 × 10 9 /L, and neutrophils 80.1 %.

By blood gas analysis, pH 7.46, PaCO 2 32 mmHg, PaO 2 58.8 mmHg, AB 22.2 mmol/L and BE −1.6 mmol/L. By blood biochemistry, K + 4.38 mmol/L, Na + 134.7 mmol/L, CK 1631.1 mmol/L, LDH 228.9 mmol/L and GOT 50.3 U/L.

By the four coagulation indices test, PT 14.5 s and PTA 59.3 %.

Diagnostic Imaging By chest X-ray on Oct. 30th, 2009 (Fig. 11.62a ) , large fl aky cloudy shadows with increased density in both lower lungs; enlarged and thickened hilum of the right lung.

By chest CT scanning on Oct. 30th, 2009 (Fig. 11 .62 b1-c2), symmetrical large fl aky shadows with increased density in posterior basal segments of both lower lungs, with gas bronchogram. Figure 11 .62 d1-e2: pulmonary tissues parenchymal changes in mediastinal window.

By chest CT scanning on Nov. 2nd, 2009 ( Fig. 11 .62 f1l), symmetrical large fl aky shadows with increased density in posterior basal segments of both lower lungs, with gas bronchogram; improved conditions compared to chest X-ray fi ndings on Oct. 30th, 2009. By chest CT scanning on Nov. 5th, 2009 (Fig. 11 .62m-t ), symmetrical large fl aky shadows with increased density in posterior basal segments of both lower lungs, with gas bronchogram; improved conditions compared to chest X-ray fi ndings on Nov. 2nd, 2009. By chest CT scanning on Nov. 9th, 2009 (Fig. 11 .62u-x ), increased and deranged lung markings; no other abnormalities; improved conditions compared to chest X-ray fi ndings on Nov. 5th, 2009.

By chest X-ray on Nov. 9th, 2009 ( Fig. 11 .62y, z ): no abnormalities in both lungs and cardiac diaphragm.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports History of Present Illness . A 45-years-old man, complained of intermittent fever and cough for 5 days, with accompanying slight cough with a little whitish phlegm, no chills and runny nose. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C. Pharyngeal congestion with tonsils swollen to I degree. Moist rale in the right lung. By routine blood tests on Nov. 15th, 2009, leukocytes count 5.49 × 10 9 /L, lymphocytes 23.7 % and neutrophils 66.5 %.

Diagnostic Imaging By chest X-ray on Nov. 15th, 2009 (Fig. 11.63a ) , thickened lung markings of both lungs; decreased transparency of the right lower lung; patchy shadows in the right lower lung.

By chest X-ray on Nov. 18th, 2009 (Fig. 11.63b ) , thickened lung markings of both lungs; decreased transparency of both lungs; patchy shadows in the right lower lung; improved conditions compared to chest X-ray fi ndings on Nov. 15th, 2009.

By chest X-ray on Nov. 20th, 2009 (Fig. 11.63c ), patchy shadows in both lower lungs; no obvious changes compared to chest X-ray fi ndings on Nov. 18th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). a b c Fig. 11 .63 11.7 Cases Reports

History of Present Illness . A 21-years-old woman, complained of fever and cough for 9 days, with accompanying cough with yellowish phlegm. No chills, convulsion, sore throat, nasal obstruction, rhinorrhea, chest pain and diarrhea. She received therapies of cefuroxime and Phlegm Heat Clearer prescribed by a physician from a nearby clinic with no favorable outcomes. Body temperatures between 38 and 38.7 °C. Cough and expectoration not relieved, with chest distress and shortness of breath. Past History . None. Contact History . Self reported no history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.7 °C. Pharyngeal congestion. Tonsils swollen to I degree. Moist rale in both lungs but none after cough. ESR 98 mm/h. On Nov. 18th, 2009, sputum smearing found no acidfast bacilli.

By arterial blood gas analysis on Nov. 19th, 2009, pH 7.542, PaO 2 130 mmHg and PaCO 2 28.3 mmHg.

History of Present Illness . A patient complained of sore throat, dry cough and fever for 3 days, with runny nose but no chills and fatigue.

Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 37.8 °C. Pharyngeal congestion. Tonsils not swollen. By routine blood tests on Aug. 2nd, 2009, leukocytes count 4.8 × 10 9 /L, lymphocytes 34.7 % and neutrophils 41.9 %.

Diagnostic Imaging On July 31st, 2009 ( Fig. 11 .64 ), round liked shadows with increased density in the right lower lung, with blurry boundaries.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Diagnostic Imaging . By chest X-ray on Nov. 14th, 2009 (Fig. 11.65a ) , large fl aky shadows in the inner zone of the right middle-lower lung and the left lower lung, with blurry boundaries; several cavity shadows in both lower lungs, with blurry boundaries.

By chest CT scanning on Nov. 14th, 2009 (Fig. 11 .65bm ): fl aky fl occulent cloudy shadows in both lungs fi elds; parenchymal shadows in the left lower lung; thin walled cavities and dilated bronchi shadows in both upper lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 23-years-old man, complained of fever and cough for 4 days, with accompanying rhinorrhea. Past History . Chronic gastroenteritis for more than 10 years. Icterohepatitis in childhood.

Contact History . Some students from the school he was studying in were diagnosed as In fl uenza A (H1N1).

Signs . Body temperature 39.7 °C. Pharyngeal congestion. Tonsils swollen to I degree. Coarse respiration sound in both lungs, with no moist rale. (Fig. 11.66a ): diffusive echo of hepatic parenchyma with slight changes; spleen thickness 4.8 mm.

By chest CT scanning on Nov. 5th, 2009 (Fig. 11 .66b-f ): decreased transparency of the right lung, with fl aky shadows; small fl aky shadows in the left lower lung beside the heart margin.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 50-years-old man, complained of cough and fever for a week. He was hospitalized due to deteriorating conditions for 1 day. He also had chest distress, spasmodic breathing and cough up yellowish phlegm. Past History . Type II diabetes. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.8 °C. Pharyngeal congestion. Edema.

Diagnosis . Critical In fl uenza A (H1N1); pneumonia of both lungs; Type I respiratory failure; metabolic acidosis; renal dysfunctioning; hypertension (extremely critical).

Laboratory Diagnostic Imaging By chest X-ray on Nov. 2nd, 2009 ( Fig. 11.67 ) , blurry lung markings of both lungs; decreased transparency of both lungs; patchy shadows in both middle-lower lungs, with blurry boundaries.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 54-years-old woman, complained of fever for 6 days and cough for 4 days and was hospitalized. She had persistent fever, cough with phlegm (a little odorless whitish phlegm).

Past History . None. Contact History . Denied history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C. Pharyngeal congestion. Tonsils not swollen. Moist rale in both lungs.

Laboratory By blood gas analysis on Nov. 14th, 2009, pH 7.469, PaCO 2 37.6 mmHg and PaO 2 71 mmHg.

By routine blood tests, leukocytes count 4.93 × 10 9 /L, lymphocytes 10.3 % and neutrophils 87.5 %.

By blood gas analysis on Nov. 15th, 2009, pH 7.382, PaCO 2 39.4 mmHg and PaO 2 54.1 mmHg.

By routine blood tests, leukocytes count 4.95 × 10 9 /L, lymphocytes 17.0 % and neutrophils 77.5 %.

By liver function test on Nov. 16th, 2009, ALT 101.8 U/L and AST 120.4 U/L. By blood gas analysis, pH 7.418, PaCO 2 48 mmHg and PaO 2 135.5 mmHg.

Diagnostic Imaging By chest X-ray on Nov. 14th, 2009 (Fig. 11.68a ): large fl aky shadows with increased density in both middle-lower lungs; decreased transparency of both lungs; thickened hilum of both lungs.

By chest X-ray on Nov. 17th, 2009 (Fig. 11.68b ): fl aky shadows with increased density in both middle-lower lungs; progressive conditions compared to chest X-ray fi ndings on Nov. 14th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). Diagnostic Imaging By chest X-ray on Oct. 30th, 2009 (Fig. 11.70 ) : increased lung markings of both lungs; cloud mist liked shadows with increased density; enlarged and thickened pulmonary hilum.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1).

History of Present Illness . A 21-years-old man, complained of fever, sore throat and dry cough for 2 days, with chills, shivering, sore throat and cough. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 38.9 °C. Pharyngeal congestion. Tonsils swollen to II degree.

Laboratory Tests By throat swabs, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) positive, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) positive.

By routine blood tests on July 5th, 2009, leukocytes count 3.0 × 10 9 /L, lymphocytes 38.9 % and neutrophils 44.56 %.

By routine blood tests on July 7th, 2009, leukocytes count 3.2 × 10 9 /L, lymphocytes 53.6 % and neutrophils 32.3 %.

Diagnostic Imaging By chest X-ray on July 7th, 2009 ( Fig. 11.69 ) , fl aky and strip liked shadows in inner zone of the left upper lung; enhanced lung markings; increased and thickened pulmonary hilum.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 2-years-old boy, had chief complaints of fever and cough for 2 days, with runny nose but no chills and fatigue. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.6 °C. Pharyngeal congestion. Tonsils swollen to I degree.

Laboratory By routine blood tests, leukocytes count 5.9 × 10 9 /L, lymphocytes 51.6 %, neutrophils 42.6 % and platelets count 190 × 10 9 /L. Diagnostic Imaging By chest X-ray on Nov. 1st, 2009 (Fig. 11.71a ) , diffusive patchy shadows in both lungs; blurry lung markings, predominantly in the right lung.

By chest X-ray on Nov. 2nd, 2009 (Fig. 11.71b ) , blurry pulmonary markings of both lungs; enlarged and thickened hilum, predominantly in the both lower lungs; improved conditions compared to chest X-ray fi ndings on Nov. 2nd, 2009.

Diagnosis . Pneumonia complicating critical In fl uenza A (H1N1). a b Fig. 11 .71

Case 11.72

History of Present Illness . A patient complained of fever and cough for 3 days. Phlegm dif fi cult expectorating; diarrhea but no chills and fatigue. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C. Pharyngeal congestion. Tonsils swollen to I degree. Moist rale in both lungs.

Laboratory Tests By throat swabs on Nov. 12th, 2009, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) negative, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) negative.

By routine blood tests on Nov. 13th, 2009, leukocytes count 4.119 × 10 9 /L, lymphocytes 51.6 % and neutrophils 36.5 %.

Diagnostic Imaging By chest X-ray on Nov. 12th, 2009 (Fig. 11.72a ) , small fl aky cloudy shadows in the left lower lung.

By chest X-ray on Nov. 14th, 2009 (Fig. 11.72b ) , multiple small patchy cloudy shadows in both lower lungs; blurry lung markings; no obvious changes compared to chest X-ray fi ndings on Nov. 12th, 2009.

By chest X-ray on Nov. 16th, 2009 (Fig. 11.72c ) , cloud mist liked blurry shadows in both lower lungs; blurry lung markings; enlarged and thickened pulmonary hilum; progressive conditions compared to chest X-ray fi ndings on Nov. 14th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 37-years-old man, complained of fever and cough for 7 days, with expectoration of whitish or yellowish phlegm. Past History . None. Contact History . Denied history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C. Pharyngeal congestion. Tonsils not swollen. Coarse respiration sound in both lungs. No moist rale. Heart rate 100 beats/min. Sub-types of T-lymphocytes counts, CD4 + 328 × 10 6 /L, CD8 + 199 × 10 6 /L, and CD4 + /CD8 + 1.6.

Sputum culture on Nov. 19th, 2009 negative. Diagnostic Imaging By chest X-ray on Nov. 15th, 2009 (Fig. 11.73a ) , increased and blurry lung markings of both lower lungs; cloud mist liked shadows with increased density; enlarged and thickened pulmonary hilum.

By chest CT scanning on Nov. 16th, 2009 (Fig. 11.73b-k ) , large fl aky blurry shadows in posterior basal segments of both lungs; parenchymal changes of some pulmonary tissues; gas bronchogram more obvious in the right lung.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 39-years-old woman, complained of cough deterioration and fever for 5 days, with headache, chills, muscle soreness, fatigue and expectoration of whitish thick phlegm. Past History . None. Contact History . Self reported of coming from the epidemic area of In fl uenza A (H1N1).

Signs . Body temperature 39 °C. Pharyngeal congestion. Tonsils swollen to I degree. Moist rale in both lungs.

Laboratory Tests By throat swabs on Nov. 19th, 2009, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) negative, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) negative.

By routine blood tests, leukocytes count 3.39 × 10 9 /L and neutrophils 70.25 %.

By routine blood tests on Nov. 22nd, 2009, leukocytes count 2.72 × 10 9 /L, lymphocytes 36.4 % and neutrophils 53.2 %.

Diagnostic Imaging By chest X-ray on Nov. 22nd, 2009 (Fig. 11.74 ) , thickened lung markings of both lungs; patchy blurry shadows in both middle-lower lungs; both diaphragmatic surfaces blurry.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 40-years-old man, complained of fever and cough for 5 days and dyspnea for 1 day, with chills and chest distress. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39 °C. Pharyngeal congestion. Tonsils not swollen.

Laboratory By routine blood tests, leukocytes count 2.83 × 10 9 /L, lymphocytes 37.1 % and neutrophils 59.4 %.

By blood gas analysis, pH 7.512, PaCO 2 30 mmHg and PaO 2 34 mmHg.

Diagnostic Imaging By chest X-ray on Nov. 16th, 2009 (Fig. 11.75a ) : increased pulmonary markings of both lungs; fl aky blurry shadows in both lower lungs; enlarged and thickened pulmonary hilum.

By chest X-ray on Nov. 17th, 2009 (Fig. 11.75b ): increased pulmonary markings of both lungs; fl aky blurry shadows in both lower lungs; improved conditions compared to chest X-ray fi ndings on Nov. 16th, 2009.

By chest X-ray on Nov. 18th, 2009 (Fig. 11.75c ): increased pulmonary markings of both lungs; fl aky blurry shadows in both lower lungs; no obvious changes compared to chest X-ray fi ndings on Nov. 17th, 2009.

By chest X-ray on Nov. 20th, 2009 (Fig. 11.75d ) : cloud mist liked shadows in both lungs fi elds; decreased transparency of both lungs; slightly progressive conditions compared to chest X-ray fi ndings on Nov. 17th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 16-years-old boy, complained of recurrent chest distress and suffocation for 4 years, with fever and cough for 4 days. Past History . Self reported diagnosis of asthma 4 years ago.

Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 37 °C. Mental conditions good. Pharyngeal congestion.

Laboratory Diagnostic Imaging By chest CT scanning on Nov. 4th, 2009 (Fig. 11.76a-g ) , scattered ground glass liked of fl aky fl occulent shadows in both lungs; bronchial walls thickened.

By chest CT scanning on Nov. 9th, 2009 (Fig. 11.76h-o ) : thickened pulmonary markings of both lungs; improved conditions compared to chest CT scanning on Nov. 4th, 2009.

By chest CT scanning on Nov. 11th, 2009 (Fig. 11.76p-t History of Present Illness . A 37-years-old man, complained of intermittent cough with yellowish thick phlegm. Past History . None. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 37 °C. Breathing rate 18-24 times/min. Heart rate 69-84 beats/min. Blood pressure (100-110)/(66-70) mmHg. Pharyngeal congestion. Respiration sound of both lungs low, with rare or moderate fi ne moist rale in both lower lungs but no dry rale. Cardiac border slightly enlarged toward left, with heart rate 98 beats/min. History of Present Illness . A 19-years-old man, complained of fever for 6 days and dyspnea with cough and expectoration for 5 days. The patient suffered from fever due to catching a cold 6 days before his hospitalization, with the highest temperature 38 °C. He also had cough, dif fi culty breathing, expectoration of yellowish and sometimes blood phlegm.

The sputum small in amount. Diagnosis on admission: (1) critical In fl uenza A (H1N1).

(2) critical pneumonia; type 2 respiratory failure; ARDS. By routine blood tests, leukocytes count 7.9 × 10 9 /L. By blood gas analysis, pH 7.38, PaCO 2 56 mmHg, PaO 2 150 mmHg, BE 5.6 mmol/L, Signs . Pharyngeal congestion. Respiration sounds in both lungs low. Decreased moist rales.

ECG . Sinus rhythm; atrioventricular block of I degree.

Diagnostic Imaging By chest CT scanning on Nov. Signs . Acute appearance. Shortness of breath. Facial blushing. SpO 2 80-90 %. Breathing rate 45 times/min. Heart rate 105 beats/min. Respiration sounds of both lungs lower. Tracheal migration not obvious.

Diagnostic Imaging By chest CT scanning on Nov. 25th, 2009 (Fig. 11.78k-n ) , strip liked gas shadows in the external zone of both lungs; 30 % compressed pulmonary tissues of both lungs; lung volume of both lungs decreased; gathered pulmonary markings; parenchyma changes of both lower lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports Diagnostic Imaging By chest CT scanning on Nov. 6th, 2009 (Fig. 11 .79a-f ), fl aky shadows with increased density in posterior basal segment of the right lung, with blurry boundaries; increased and thickened pulmonary markings of the rest lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 35-years-old man, complained of fever, cough and expectoration for 6 days, and worsened conditions for 3 days. He also had chills, headache, general soreness, paroxysmal cough with small amount of whitish foamy phlegm. The cough deteriorated 3 days ago, with large amount of whitish foamy phlegm about 60 mL per day and occasional bloody phlegm. Past History . Denied histories of major basic diseases.

Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs By routine blood tests, leukocytes count 11.1 × 10 9 /L, hemoglobin 154 g/L. By coagulation tests, PT 9.3 s, PTA 154.5 % and APTT 26.9 s.

By blood biochemistry, ALT 81 U/L, AST 39 U/L, PA 351 mg/L, CK 37 U/L, CK-MB 12 U/L, HBDH 139 U/L, LDH 174 U/L, blood lactate 1.7 mmol/L, renal function and electrolytes normal, improved liver function.

Humoral Immunity: IgG 22.05 g/L and the other indices normal.

By sputum smear, a great amount of G + coccus; a small amount of G − coccus and G − bacillus.

Diagnostic Imaging By chest CT scanning on Nov. 24th, 2009 (Fig. 11 .80a-f ): fl aky shadows with increased density in internal segment and basal segment of the both lower lungs; thickened bilateral pleura.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 32-years-old man, complained of fever, cough and sore throat for 6 days, and shortness of breath for 2 days. The highest body temperature 41 °C, with sore throat, cough and occasional expectoration of a little whitish foamy phlegm. On Nov. 14th, 2009, the patient started to have orthopnoea and bloody sputum. His spirituality and appetite remained poor. On Nov. 16th, 2009, he had bad coughs with a little pink foamy phlegm. Moist wheezing diffused in both lungs, especially in the right lung.

On Nov. 18th, 2009, he had no fever, but occasional coughs with a little yellowish phlegm. By physical examinations, pharyngeal congestion; tonsils swollen to I degree; moist wheezing in both lungs obviously decreased.

On Nov. 19th, 2009, he coughed a little mucoid phlegm with blood after getting up in the morning. By physical examination, pharyngeal congestion; moist wheezing in both lungs obviously decreased, with no dry wheezing.

On Nov. 20th, 2009, he had bad coughs with a little mucous bloody phlegm. By physical examination, pharyngeal congestion; moist wheezing in both lungs obviously decreased, with occasional dry wheezing.

Past History . None. Contact History . Self reported history of contacting with patients suffering from fl u liked symptoms within 1 week. Denied history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 36.7 °C. Heart rate 107 beats/ min. Breathing rate 25 times/min. Blood pressure 119/79 mmHg, SpO 2 88 %. Appearance of acute diseases. Orthopnoea. Conscious. Spirituality good. Pharyngeal congestion. The tonsils swollen to I degree. Shortness of breath. Much moist wheezing in both lungs. Dry wheezing in the right middle-lower lung.

Diagnostic Imaging CT scanning on Nov. 14th, 2009 ( Fig. 11.81a-h ) , patchy shadows and ground glass liked shadows in both lungs, especially in posterior basal segment of both lower lungs.

By chest X-ray on Nov. 17th, 2009 (Fig. 11.81i ) , cloud mist ground glass liked shadows with increased density in both lungs; blurry pulmonary hilum.

By chest X-ray on Nov. 18th, 2009 (Fig. 11.81j ) , cloud mist ground glass liked shadows with increased density slightly faded; increased transparency of both lungs compared to chest X-ray fi ndings on Nov. 17th, 2009. By chest CT scanning on Nov. 20th, 2009 (Fig. 11 .81k-q ), absorbed shadows and improved conditions of both lungs compared to chest CT scanning on Nov. 15th, 2009, increased transparency of both lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 45-years-old man, complained of recurrent cough and fever for 10 days. Past History . He was diagnosed as having acute myeloid leukemia M2a 10 months ago and received blood transfusion of ten units type O red blood cell suspensions and eight units platelet.

Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion. Respiration sound in both lungs low, with a little moist wheezing in both lower lungs. Signs . Pharyngeal congestion. Diagnostic Imaging By chest X-ray on Nov. 12th, 2009 (Fig. 11.84 ), increased and deranged lung markings of both lungs; spotty fl aky blurry shadows; enlarged and thickened pulmonary hilum.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By chest X-ray on Nov. 9-10th, 2009 ( Fig. 11.85c, d ) , fl aky cloudy shadows with increased density in both lungs; decreased transparency of both lungs;0 obviously improved conditions compared to chest X-ray fi ndings on 2009-11-8.

By chest X-ray on Nov.13-16th, 2009 ( Fig. 11 .85e, f ), diffusive cloudy shadows with increased density in both lower lungs; decreased transparency of both lungs; enlarged and blurry hilum; expanded fi eld with blurry dense shadows compared to chest X-ray fi ndings on Nov. By routine blood tests on Sep. 18th, 2009, leukocytes count 27.33 × 10 9 /L, neutrophils 80.7 % and hemoglobin 92 g/L.

By blood gas analysis, PaCO 2 34 mmHg, PaO 2 48 mmHg, SpO 2 85 %; blood Na + 132.2 mmol/L. By coagulation tests, PT 21.9 s and APTT 33. By chest X-ray on Nov. 19th, 2009 (Fig. 11.87g ), diffusive shadows with increased density in the right lung fi eld; the right lung compressed by 80 %; obviously improved conditions of the left lung and progressive conditions of both lower lungs compared to chest X-ray fi ndings on Nov. 17th, 2009.

By chest CT scanning on Nov. 19th, 2009 (Fig. 11.87h-k ) , no transparency area of lung markings in the right lung; visible gas-fl uid level; hydropneumothorax in the right lung; compressed and gathering pulmonary tissues of the right lung; mediastinum rightward migration; a small amount of effusion in the left chest cavity. By pleural effusion test, purulent effusion of the chest cavity.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). By routine blood tests on Nov. 16th, 2009, leukocytes count 5.0 × 10 9 /L, neutrophils 58.3 %, lymphocytes 33.5 %, erythrocytes count 5.3 × 10 12 /L, hemoglobin 161 g/L, platelets count 187 × 10 9 /L. By blood biochemistry, CRP 19 mg/L, HBDH 185 U/L. Diagnostic Imaging By chest CT scanning on Nov. 13th, 2009 (Fig. 11.88a -d ) , ground glass liked shadows in the dorsal segment of the right lower lung and in the posterior basal segment of the right lower lung; lobular central nodular/patchy shadows with air cavities.

By chest CT scanning on Nov. 16th, 2009 (Fig. 11 .88e -h ), ground glass liked/patchy shadows in the dorsal segment and the posterior basal segment of the right lower lung; obviously absorbed foci and improved conditions compared to chest CT scanning on Nov. 13th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 59-years-old woman, complained of fever, chest pain, cough and expectoration of whitish foamy phlegm, general soreness, headache and fatigue. Her highest body temperature was 39.8 °C, with sore throat, tightness of breath, expectoration of yellowish thick phlegm, palpitation, shortness of breath and bloody yellowish phlegm. Past History . History of hypertension for 26 years. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs . Respiration sounds low. Fine moist wheezing in both lower lungs and diffusive dry wheezing in both lower lungs. The heart oversized relative to the dullness area. Heart rate 78 beats/min. Heart rhythm regular. Diagnosis on admission: (1) In fl uenza A (H1N1) and critical pneumonia of both lungs; hypoxemia; Type I respiratory failure.

(2) Acute episode of chronic bronchitis; emphysema; chronic obstructive pulmonary disease. Diagnostic Imaging By chest CT scanning on Nov. 8th, 2009 (Fig. 11.89a-d ) , patchy shadows with increased density in both lower lungs.

By chest CT scanning on Nov. 9th, 2009 (Fig. 11 .89e-h ), patchy shadows with increased density in both lower lungs; no obvious changes compared to chest CT scanning on Nov. 8th, 2009.

By chest CT scanning on Nov. 11th, 2009 (Fig. 11 .89i-l ), patchy shadows with increased density in both lower lungs; obviously improved conditions compared to chest CT scanning on Nov. 9th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 31-years-old man, complained of cough, expectoration and throat soreness for 10 days; fever and tightness of breath for 4 days. The patient suffered from a cold and cough 10 days ago, with a little whitish foamy phlegm and throat soreness. Four days before hospitalization, he suffered from fever and chills, with the highest body temperature of 39 °C and bloody phlegm. He reported tightness of breath, tidal fever, spontaneous sweating and chills when coughing and talking. Past History . HBV carrier, with normal liver function. Contact History . Denied history of contacting with In fl uenza A (H1N1) patients.

Signs . Pharyngeal congestion. The right tonsil swollen to I degree and the left tonsil not swollen. Respiration sounds in both lungs lowered. Moderate and fi ne moist wheezing in both lungs, especially in the right lung.

Laboratory By routine blood tests, leukocytes count 4.8 × 10 9 /L, lymphocytes count 7.9 %, neutrophils 89.5 %.

By blood gas analysis, pH 7.36, PaCO 2 60 mmHg, PaO 2 51 mmHg, BE 5.2 mmol/L, 3 HCO -32.8 mmol, SaO 2 86 %, Na + 138 mmol/L, K + 4.0 mmol/L. On Nov. 23rd, 2009, sputum smear twice found a great amount of positive coccus, a small amount of negative coccus and negative bacillus, with fungal spores.

By routine blood tests, leukocytes count 12.6 × 10 9 /L, neutrophils 94.4 %, increased compared to the previous tests fi ndings.

By blood biochemistry, ALT 291 U/L, AST 136 U/L, CRP 5.6, LACT 5.0 mmol/L. Electrolytes: Na + 132.9 mmol/L, K + 4.64 mmol/L; HBDH 243 U/L, LDH 315 U/L. Increased myocardial enzyme of the liver function compared to the previous tests fi ndings.

Diagnostic Imaging Chest CT scanning on Nov. 18th, 2009 ( Fig. 11 .90a-f ), patchy cloudy shadows with increased density and ground glass liked shadows in both lungs, especially in posterior basal segments of both lower lungs, with gas bronchogram.

Chest CT scanning on Nov. 21st, 2009 (Fig. 11 .90 g-k ), patchy cloudy shadows with increased density in both lungs, especially in posterior basal segments of both lower lungs; obviously progressive conditions compared to chest CT scanning on Nov. 18th, 2009.

Chest CT scanning on Nov. 23rd, 2009 (Fig. 11 .90l-r ), patchy cloudy shadows with increased density in both lungs, especially in posterior basal segments of both lower lungs, with gas bronchogram; slightly absorbed foci and improved conditions compared to chest CT scanning on Nov. 21st, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports History of Present Illness . A 28-years-old man, complained of fever and cough for 1 day, with expectoration of yellowish thick phlegm, chills, shivers, rhinorrhea and nasal obstruction.

Past History . Histories of hepatitis A and tuberculosis 10 years ago.

Contact History . Self reported history of contacting with patients suffering from fl u liked symptoms within a week.

Laboratory On Nov. 18th, 2009, blood gas analysis found pH 7.437, PaCO 2 31.4 mmHg, PaO 2 68 mmHg, EB-3 mmol/L, 3 HCO -21.2 mmol/L. Routine blood tests found leuko-cytes count 6.46 × 10 9 /L, neutrophils 90.3 %, platelets count 111 × 10 9 /L, hemoglobin 143 g/L.

On Nov. 19th, 2009, blood biochemistry found PA 175 mg/L; CRP 119.4 mg/L; LACT 2.2 mmol/L; PT 15.6 s. Routine blood tests found leukocytes count 7.8 × 10 9 /L, neutrophils 86.7 % and lymphocytes 9.8 %.

Diagnostic Imaging By chest CT scanning on Nov. 18th, 2009 (Fig. 11.91a-d ) , fl aky or ground glass liked shadows in the posterior basal segment of the left low lung.

By chest CT scanning on Nov. 21st, 2009 (Fig. 11.91e-h ) , fl aky or ground glass liked shadows in the posterior basal segment of the left lower lung; no obvious changes compared to chest CT scanning on Nov. 18th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 40-years-old man, complained of fever and cough for 3 days; dyspnea for 1 day. He also suffered from expectoration. After antiin fl ammatory medications by himself, conditions were not improved, with chest distress and dyspnea. Past History . History of diabetes. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.

Signs On Nov. 26th, 2009, blood gas analysis found pH 7.21, PaCO 2 37 mmHg, PaO 2 152 mmHg. Routine blood tests found leukocytes count 7.73 × 10 9 /L, neutrophils 89.4 %, lymphocytes 9.1 %, erythrocytes count 1.9 × 10 12 /L, hemoglobin 60 g/L. The liver functions: ALT 29 U/L, AST 35 U/L, UREA 17.63 U/L, Cr 134 U/L. On Nov. 28th, 2009, blood gas analysis found pH 7.24, PaCO 2 40 mmHg, PaO 2 108 mmHg. Routine blood tests found leukocytes count 7.67 × 10 9 /L, neutrophils 81.7 %, lymphocytes 13.4 %, erythrocytes count 2.13 × 10 12 /L, hemoglobin 67 g/L. The liver functions: ALT 62.3 U/L, AST 145 U/L, UREA 12.09 U/L, Cr 132.8 U/L.

Diagnostic Imaging By chest X-ray on Nov. 25th, 2009 (Fig. 11.92a ) , decreased transparency of the right lung and the left middle-lower lung; intrapulmonary large fl aky shadows with increased density; enlarged and blurry hilum.

By chest X-ray on Nov. 26th, 2009 ( Fig. 11 .92b ), decreased transparency of the right lung and the left middle-lower lung; intrapulmonary large fl aky shadows with increased density; enlarged and blurry hilum; progressive conditions compared to the chest X-ray fi ndings on Nov. 25th, 2009.

By chest X-ray on Nov. 28th, 2009 (Fig. 11.92c ), decreased transparency of the right lung and the left middle-lower lung; intrapulmonary large fl aky shadows with increased density; enlarged and blurry hilum; progressive conditions compared to the chest X-ray fi ndings on Nov. 26th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 11.7 Cases Reports By chest X-ray on Nov. 30th, 2009 (Fig. 11.93d ) , diffusive shadows with increased density in both lungs; hilum enlarged and blurry; the upper bound of diaphragm covered; obviously progressive conditions compared to chest X-ray fi ndings on Nov. 27th, 2009.

By chest X-ray on Dec. 2nd, 2009 (Fig. 11 .93e ), diffusive shadows with increased density in both lungs; hilum enlarged and blurry; the upper bound of diaphragm covered; slightly improved conditions compared to chest X-ray fi ndings on Nov. 30th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 24-years-old man, complained of fever and cough for 5 days. After therapies of azithromycin in another hospital and You'an Hospital in Beijing, his conditions were not improved, with recurrent fever and deteriorated cough. On the fi fth day after disease onset, he was hospitalized due to positive throat swabs. Past History . None related to the present illness. Contact History . Not de fi nitive history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 39.6 °C. Conscious but poor spirituality. Pharyngeal congestion. Tonsils not swollen. The respiration sound of the left lungs low, with no dry and moist rale. ECG . Sinus rhythm. Diagnostic Imaging By chest CT scanning on Nov. 30th, 2009 (Fig. 11 .94a-f ), scattered patchy blurry shadows in posterior segments of both lower lungs.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 41-years-old man, complained of fever and cough for 4 days. He had fever 4 days ago, with a body temperature of 40 °C, with cough, no phlegm, sore extremities and fatigue. Therapies of ephalosporins and penicillin infusion showed no favorable outcomes in the local countryside clinic. Then he received oseltamivir therapy 1 day ago in the local hospital, with outcomes of chest tightness and the shortness of breath after activities. The patients was then transferred into the clinic of You'an Hospital in Beijing. On the fourth day after disease onset, he was hospitalized due to positive throat swabs. Past History . The right collar bone fracture 10 years ago. No histories of other illnesses.

Contact History . Self reported none de fi nitive history of contacting with In fl uenza A (H1N1) patients.

Signs . Body temperature 36.9 °C. Heart rate 92 beats/ min. Respiration 23 times/min. Conscious but poor spirituality. No lips cyanosis. Tonsils not swollen. Respiration sound of the left middle lung low, with no dry and moist rales. Heart sound powerful with regular rhythm. No murmurs in the heart valvar areas.

Laboratory On Nov. 28th, 2009, routine blood tests found leukocytes count 4.1 × 10 9 /L, lymphocytes 46.10 % and neutrophils 38.30 %.

On Nov. 28th, 2009, HBV-M found HBsAb (+) , and the other indices negative; HCVAb (−); syphilis (−).

On Nov. 29th, 2009, blood gas analysis found pH 7.379, PaO 2 103 mmHg, PaCO 2 39.8 mmHg, SaO 2 98 %, 3 HCO -23.5 mmol/L, BE −2 mmol/L. On Dec. 1st, 2009, subtypes of T-lymphocytes were CD4 + 816 × 10 6 /L, CD8 + 516 × 10 6 /L, CD4 + /CD8 + 1.58.

Diagnostic Imaging By chest CT scanning on Dec. 1st, 2009 (Fig. 11.96a-d ) , extensive cloudy fl occulent shadows in both lungs; poor transparency of both lungs, especially the left lung; unsmooth bilateral pleura.

By chest CT scanning on Dec. 1st, 2009 ( Fig. 11 .96e-h ), intrapulmonary patchy shadows with slightly increased density; blurry boundaries; uneven densities within shadows; obviously improved conditions compared to chest CT scanning on Nov. 28th, 2009.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 58-years-old man, complained of fever and cough for 3 days, with a little yellowish and whitish phlegm. He was admitted to You'an Hospital in Beijing due to positive throat swabs. Past History . History of hypertension for 3 years Contact History . No de fi nitive history of contacting with In fl uenza A (H1N1) patients.

Signs . The highest body temperature 39 °C. Pharyngeal congestion obvious. Tonsils not swollen. Respiration sound of both lungs coarse, with obvious moist rales in both lungs.

Laboratory On Nov. 20th, 2009, routine blood tests, leukocytes count 3.4 × 10 9 /L, neutrophils 43.9 %, lymphocytes 16.1 %.

On Nov. 20th, 2009, routine blood tests, leukocytes count 3.39 × 10 9 /L, neutrophils 81.4 %, lymphocytes 41.52 %.

On Nov. 24th, 2009 blood biochemistry found AST 36 U/L, renal function normal, electrolytes normal, LDH 252 U/L, CK 213 U/L and AK 5.45 U/L. HBV-M negative.

ECG . Normal. Diagnostic Imaging By chest CT scanning on Nov. 21st, 2009 (Fig. 11.98a-c ) , scattered patchy blurry shadows of both lungs, with blurry boundaries.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 70-years-old man, complained of recurrent fever and cough for more than 10 years. He self reported mental tiredness and swollen legs for 4 years, poor appetite for 9 days and fever for 3 days. At 17:00 on Sep. 12th, 2009, he was admitted with clinical diagnosis of severe In fl uenza A (H1N1) and pneumonia of both lungs; type II respiratory failure; acute episode of chronic bronchitis; obstructive pulmonary emphysema; heart originated heart diseases; heart failure; heart function of grade III to IV; bronchiectasis; type II diabetes and diabetic peripheral neuropathy; diabetic nephropathy; cataracts; respiratory acidosis and metabolic alkalosis.

Past History . Histories of chronic obstructive pulmonary disease and diabetes.

Laboratory Tests By throat swabs, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) negative, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) positive.

By routine blood tests, leukocytes count 10.9 × 10 9 /L, neutrophils 85.0 %, platelets count 113 × 10 9 /L. Blood gas analysis found pH 7.4, PaO 2 92 mmHg, PaCO 2 59 mmHg, BE 9 nmol/L, CRP 171.4 mg/L, BUN 11.0 mmol/L, Cr normal, liver functions normal, myocardial enzyme normal, blood coagulation time within normal limits.

Diagnostic Imaging By chest X-ray on Sep. 12th, 2009 ( Fig. 11.100a, b ) , fl aky blurry shadows with increased density in the both lower lungs; enlarged and blurry hilum.

By chest CT scanning on Sep. 12th, 2009 (Fig. 11 .100ch ), infectious foci in the left lung, anterior segment of the right upper lung, posterior basal segment of the right lower lung, lateral basal segment of the right lung; slight bronchiectasis in the lower lobes of both lungs; bronchitis emphysema of both lungs; aortic diameter about 4.0 cm; the trunk diameter of pulmonary artery about 3.3 cm.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 75-years-old woman, complained of fever, expectoration and fever for 4 days. After a history of contacting with a In fl uenza A (H1N1) patient, she started to have fever 4 days before admission, with the highest body temperature of 39 °C. She also had serious cough with yellowish phlegm but with dif fi culty expectorating, headache, sore throat, tightness of breath, self reported mental tiredness, poor appetite. After self administration of medicines for the cold, her body temperature decreased, but recurrent without to the normal level. Past History . History of hypertension. Contact History . Self reported history of contacting with a In fl uenza A (H1N1) patient.

Signs . Body temperature 37.4 °C. Heart rate 100 beats/ min. Breathing rate 26 times/min. Blood pressure 110/70 mmHg, SpO 2 94 %. Jugular vein obvious distention. Hepatojugular re fl ux positive. Vocal fremitus of both lungs weakened. Hyper resonance on percussion. Downward migration of the lower bound of lung. Shortness of breath. Respiration sound of both lungs low. Moderate to fi ne moist rales in both middle lower lungs, especially in the left lung; rare to moderate low dry rales of double phase in both lungs. Relative dullness of the heart. Heart bound extended leftward. Heart rate 100 beats/ min. Heart rhythm regular. Heart sounds of S1 and S2 normal, with A2 > P2. Mild pitting edema under the knees of legs.

Laboratory Tests By throat swabs, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) negative, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) negative.

By routine blood tests, leukocytes count 10.0 × 10 9 /L, neutrophils 73.0 %, platelets count 113 × 10 9 /L. Blood gas analysis found pH 7. 4, PaO 2 92 mmHg, PaCO 2 59 mmHg, BE 9 mmol/L. By blood biochemistry, CRP 171.4 mg/L, BUN 11.0 mmol/L. By reexamination of blood gas analysis, pH 7.35, PaO 2 108 mmHg, PaCO 2 43 mmHg, 3 HCO -27 mmol/L. ECG . T wave low and fl at. Diagnostic Imaging By chest CT scanning on Nov. 16th, 2009 ( Fig. 11 .101a-f ), increased lung markings of both lower lungs; spotty and fl aky blurry shadows, especially posterior segment of the lower lung.

Diagnosis . Pneumonia complicating In fl uenza A (H1N1). 

Gross autopsy fi ndings: Figure 11 .105k : 72 h after death, lung tissues fi brosis and patchy bleeding. Figure 11 .105l : H&E staining found a few alveolar cells, most lung tissues fi brosis, large amount of in fl ammatory cells; intraalveolar bleeding. Figure 11 .105m : H&E staining found a few alveolar cells, most lung tissues fi brosis, no bronchiolar epithelium; large amount of in fl ammatory cells (mainly macrophages); all the fi ndings in line with diffusive alveolar impairments after necrotic bronchitis; intraalveolar bleeding. Figure 11 .105n : H&E staining found many in fl ammatory cells in hepatocellular spaces. Figure 11 .105o : H&E staining found many in fl ammatory cells in hepatocellular spaces. Figure 11 .105p : H&E staining found renal sinus dilation; many in fl ammatory cells in renal parenchymal spaces. Figure 11 .105q : H&E staining found renal sinus dilation; many in fl ammatory cells in renal parenchymal spaces. Figure 11 .105r : H&E staining found a few in fl ammatory cells in myocardial cells spaces. Figure 11 .105s : H&E staining found a few in fl ammatory cells in myocardial cells spaces.

Diagnosis . Critical In fl uenza A (H1N1). History of Present Illness . A 22-years-old woman, complained of fever in late pregnancy with no known causes. For the clinic visit, she had fever 6 days ago and had had continual fever with the highest temperature of 39 °C. She suffered from remittent fever with chills, shivers, sore throat but no pharynx soreness. In addition, she had intermittent moderate cough, with a few phlegm and shortness of breath. Two days before admission, she delivered a baby boy after natural labor and she was admitted due to obvious shortness of breath, increased frequency of breathing, cyanosis and spasmodic breathing. Her conditions progressively deteriorated and death occurred because of respiratory failure. Past History . Denied history of major basic diseases. Contact History . Denied the history of contacting with any de fi nitively diagnosed In fl uenza A (H1N1) patient or any patient with fl u liked symptoms.

Signs . Pharyngeal congestion. The highest body temperature of 39 °C.

Laboratory Tests On Nov. 30th, 2009, the throat swabs by local CDC found universal gene of fl u virus (gene HA) positive.

On Dec. 2nd, 2009, routine blood tests, blood gas analysis and blood biochemistry found leukocytes count 14.37 × 10 9 /L, hemoglobin 73 g/L, neutrophils 82 %, pH 7.38, PaCO 2 33 mmHg, PaO 2 66 mmHg, ALT 330 U/L, AST 2,650 U/L, ALB 23.7 g/L, Cr 58.9 m mol/L, UREA 2.49 nmol/L, K + 3.9 mol/L, Na + 135 mmol/L. And blood smear found rod nuclear cells 17 %, metamyelocyte 3 %.

On Dec. 7th, 2009, routine blood tests found leukocytes count 19.48 × 10 9 /L, hemoglobin 84 g/L, neutrophils 90.6 %, pH 7.40, PaCO2 35 mmHg, PaO 2 60 mmHg, SaO 2 90.9 %.

On Dec. 8th, 2009, routine blood tests found leukocytes count 11.71 × 10 9 /L, hemoglobin 70 g/L, neutrophils 91.3 %, pH 7.43, PaCO 2 40 mmHg, PaO 2 61 mmHg, SaO 2 91.7 %.

On Dec. 10-12th, 2009, sputum culture found Acinetobacter baumannii , only sensitive to polymyxin.

On Dec. 14th, 2009, routine blood tests found leukocytes count 12.81 × 10 9 /L, hemoglobin 80 g/L, neutrophils 83 %, pH 7.32, PaCO 2 58 mmHg, PaO 2 93 mmHg, SaO 2 96.3 %, ALT 23 U/L, AST 22 U/L, ALB 36.3 g/L, Cr 41.6 m mol/L, UREA 3.57 nmol/L, K + 3.8 mol/L, Na + 135 mmol/L. Sputum culture found Acinetobacter baumannii .

Diagnostic Imaging By chest X-ray on Dec. 2nd, 2009 (Fig. 11.106a ) , large fl aky shadows with increased density in both lungs; obviously decreased transparency of most lung.

By chest X-ray on Dec. 5th, 2009 (Fig. 11.106b ) , large fl aky shadows with increased density; shadows thickened and fused with parenchymal changes and obviously progressive conditions compared to chest X-ray fi ndings on Dec. 2nd, 2009.

By chest X-ray on Dec. 13th, 2009 (Fig. 11.106c ) , diffusive cloud mist liked shadows with increased density in both lungs; compared to the chest X-ray fi ndings on Dec. 5th, 2009, the shadows light and improved transparency of both lungs but still having large lesion fi eld and decreased transparency of lungs.

By chest X-ray on Dec. 27th, 2009 (Fig. 11.106d ), diffusive cloud mist liked shadows with increased density in both lungs; compared to the chest X-ray fi ndings on Dec. 13th, 2009, the shadows thickened and fused and improved transparency of both upper lungs but still having poor transparency of both lungs.

By chest CT scanning 2 h after death on Dec. 29th, 2009 ( Fig. 11 .106e-h ), large amount of effusion of bilateral chest cavities; the right hydropneumothorax.

Pathological Analysis and Autopsy Figure 11 .106i, j : pulmonary tissues surface 2 h after death; decreased lung volume, extensive fi brosis and diffusive patchy bleeding. Figure 11 .106k : H&E staining found a few alveolar cells; fi brosis of most lung tissues; many in fl ammatory cells; intraalveolar bleeding. Figure 11 .106l : H&E staining found a few alveolar cells; fi brosis of most lung tissues; no bronchiolar epithelial cells; many in fl ammatory cells (mainly macrophages); the fi ndings in line with extensive alveolar impairments after necrotic bronchitis; intraalveolar bleeding. Figure 11 .106m : H&E staining found fi brosis of lung tissues and alveolar bleeding. Figure 11 .106n : H&E staining found many in fl ammatory cells in the hepatocellular spaces; hepatic sinusoid dilation; large number of erythrocytes in phagocytes. Figure 11 .106o : H&E staining found many in fl ammatory cells in hepatocellular spaces; necrosis of liver cells in fragments. Figure 11 .106p : H&E staining found renal sinus dilation; several in fl ammatory cells in the renal parenchymal spaces. Figure 11 .106q : H&E staining found renal sinus dilation; several in fl ammatory cells in the renal parenchymal spaces. Figure 11 .106r : H&E staining found a few in fl ammatory cells in myocardial cells spaces. Figure 11 .106s : H&E staining found a few in fl ammatory cells in myocardial cells spaces. 

Laboratory Tests Throat swabs by CDC found universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) positive, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) positive. By blood gas analysis on

By routine blood tests, leukocytes count 8.2 × 10 9 /L, neutrophils 84.8 %, platelets count 95 × 10 9 /L, hemoglobin 167 g/L, PT 12.5 s, d -dimer negative. By blood biochemistry

86 mmol/L, Na + 127.6 mmol/L, Cl − 95.8 mmol/L. CK 2,232 U/L, CK-MB 58 U/L. LDH 582 U/L, HBDH 758 U/L, myocardial enzyme obviously abnormal

Leukocytes count 8.1 × 10 9 /L; by urine test, SG 1.030, BLD (++) and PRO (++)

HBDH 516 U/L, myocardial enzyme slightly decreased. By blood gas analysis

2 mmol/L, SpO 2 95 %, K + 4.0 mmol/L, Na + 136 mmol/L. By blood biochemistry on

6 g/L, globulin 26.6 g/L mmol/L, CRP 47.9 mg/L, K + 4.45 mmol/L, Na + 132.6 mmol/L, Cl − 98 mmol

myocardial enzyme slightly decreased; blood lactate 3 mmol/L. By routine blood tests, leukocytes count 5.3 × 10 9 /L, GR 82.8 %, hemoglobin 111 g/L, platelets count 23 × 10 9

0 mmol/L, SpO 2 94 %, K + 4.0 mmol/L, Na + 139 mmol/L. By blood biochemistry on

LACT 3.2 mmol/L. By routine blood tests, leukocytes count 8.2 × 10 9 /L, hemoglobin 139 g/L, platelets count 193 × 10 9 /L. ESR: 16 mm/h, PT normal. By sputum smear, positive coccus and a little negative coccus; negative bacillus and fungal spores. By blood gas analysis

2 m mol/L, CK 683 U/L, Glu 11.73 mmol/L, Cysc 1.21 mg/L, CO 2 16.9 mmol/L, HBDH 293 U/L, LDH 427 U/L, IgG 6.09 g/L, LACT 2.6 mmol/L. By routine blood tests

57 mmol/L, LACT 2.3 mmol/L, ESR 78 mm/h, PT normal and d -dimer positive. By sputum smear, a small amount of negative bacillus; no fungal spore and no acid-fast bacillus. Sputum culture found Acinetobacter baunannii/calcoaceticus complex. By blood gas analysis, pH 7.567, PaCO 2 45.5 mmHg, PaO 2 74 mmHg, BE 19 mmol/L, 3 on

(Fig. 11.87c ), diffusive shadows with increased density in the left middle-lower lung fi eld; increased transparency of the right lung with obviously improved conditions and progressive conditions of the left lung compared to chest X-ray fi ndings on

HBV-M found all indices negative, HCVAb (−), HAVIgM (−), HIVAb (−), syphilis (−)

routine blood tests found leukocytes count 17.4 × 10 9 /L, neutrophils 95.84 %, lymphocytes 3.61 %, erythrocytes count 3.35 × 10 12 /L, hemoglobin 94 g/L, platelets count 265 × 10 9

LDH 476 U/L. Blood gas analysis found pH 7.526, PaO 2 41 mmHg

(Fig. 11.99i ), diffusive shadows with increased density in the both middle lower lungs, more obvious in the left lung than in the right lung. By pathological analysis (Fig. 11.99j-l ), H&E staining showed widened pulmonary interstitial; alveolar cellulose exudates; pulmonary interstitial fi brosis

Pneumonia and respiratory failure from swine-origin in fl uenza A (H1N1) in Mexico

History of Present Illness . A 52-years-old man, complained of fever for a week, cough for 4 days and dyspnea for 1 day. He also had hyperhidrosis, shortness of breath, fatigue and diarrhea for 5 times with yellowish loose stool. Symptomatic treatment was not effective but with occurrence of respiratory distress and orthopnoea.Past History . None. Contact History . Self reported no history of having been to the epidemic area.Signs . The highest body temperature 38.5 °C. Appearance of acute diseases. Misery facial expressions. Face cyanosis. Respiratory distress. Conscious. Spirituality poor. Reluctant to talking. Lips cyanosis. Respiration sound low in both lungs. Moderate to much moist rale in both lungs, with a little dry wheezing.Laboratory Tests Throat swabs by CDC on Nov. 7th, 2009, nucleic acid of In fl uenza A (H1N1) virus positive.By routine blood tests on Nov. 7th, 2009, leukocytes count 5.6 × 10 9 /L, neutrophils 62.7 %, hemoglobin 12.7 g/L, platelets count 106 × 10 9 /L. By blood gas analysis, pH 7.36, PaCO 2 42 mmHg, PaO 2 46 mmHg, BE 3.0 mmol/L and By blood gas analysis on Nov. 13th, 2009, pH 7.470, PaCO 2 33.9 mmHg, PaO 2 71 mmHg, BE 1 mmol/L, SpO 2 95 %, 3 HCO -24.7 mmol/L, Na + 137 mmol/L, K + 4.3 mmol/L.By routine blood tests on Nov. 16th, 2009, leukocytes count 13.8 × 10 9 /L, hemoglobin 119 g/L, platelets count 296 × 10 9 /L. By blood gas analysis, pH 7.449, PaCO 2 35.6 mmHg, PaO 2 69 mmHg, BE 1 mmol/L, By sputum smear, a small amount of gram-negative bacilli.Diagnostic Imaging By chest X-ray on Nov. 7th, 2009 ( Fig. 11 .85a ), diffusive cloudy shadows with increased density in both middle-lower lungs; decreased transparency of both lungs; enlarged and blurry hilum.By chest X-ray on Nov. 8th, 2009 ( Fig. 11 .85b ), diffusive cloudy shadows with increased density in the right middle-lower lung and in the left lung; decreased History of Present Illness . A 57-years-old woman, complained of abdominal pain in the right upper quadrant for 3 days, deteriorated with chest distress and suffocation for 2 days. Conscious disturbance. Paroxysmal migrating abdominal pain. Chest distress and dyspnea.Past History . Chronic bronchitis for more than 20 years, long-term use of hormone. Edema of lower extremities. Denied histories of hypertension and diabetes but having symptoms of polyuria, polydipsia and polyphagia.Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.Signs . In coma. Over-weight. Multiple ecchymosis in whole body. Severe edema in bulbar conjunctival. Left palpebral conjunctiva bleeding. Bilateral pupils are isocoria, sensitive to light. Diffusive moist wheezing in both lungs, with occasional dry wheezing. Heart rate 102 beats/min. No pathological murmurs in cardiac valvar areas. Abdominal girth 100 cm. Abdominal tension increased. Pitting edema in areas below elbow joints and below knee joints.Laboratory Tests By throat swabs, universal gene of In fl uenza A virus (gene M) positive, universal gene of H1N1 swine fl u (gene NP) positive, speci fi c gene of In fl uenza A (H1N1) virus (gene HA) positive.

History of Present Illness . A 45-years-old woman, suffered from chills and fever 5 days ago. She also had eyes upset, dry cough, a little phlegm, chest distress and suffocation. He had been diagnosed as having bronchitis in another hospital. After anti-in fl ammatory therapy, she had chest distress and shortness of breath. Finally, she was transferred to You'an Hospital in Beijing.Past History . None related to the present illness. Contact History . Self reported history of contacting with In fl uenza A (H1N1) patients.Signs . Body temperature 39.5 °C. Pharyngeal congestion.Laboratory On Nov. 15th, 2009, blood gas analysis found pH 7.438, PaCO 2 36.5 mmHg, PaO 2 69.3 mmHg. Routine blood tests found leukocytes count 2.18 × 10 9 /L, neutrophils 84 %, lymphocytes 12.8 %.On Nov. 18th, 2009, blood gas analysis found pH 7.488, PaCO 2 33.2 mmHg, PaO 2 46.9 mmHg. Routine blood tests found leukocytes count 3.69 × 10 9 /L, neutrophils 67.7 %, lymphocytes 24.7 %. The liver functions: ALT 62.9 U/L, AST 144.4 U/L, Cr 46.3 U/L, Glu 7.45 mmol/L. On Nov. 20th, 2009, blood gas analysis found pH 7.460, PaCO 2 34 mmHg, PaO 2 79 mmHg.On Nov. 30th, 2009, blood gas analysis found pH 7.310, PaCO 2 58 mmHg, PaO 2 78 mmHg. Routine blood tests found leukocytes count 11.25 × 10 9 /L, neutrophils 83.5 %, lymphocytes 11.8 %, erythrocytes count 3.25 × 10 12 /L, hemoglobin 102 g/L. The liver functions: ALT 44 U/L, AST 149 U/L, UREA 4.83 U/L, Cr 33.5 U/L.Diagnostic Imaging By chest X-ray on Nov. 25th, 2009 ( Fig. 11 .93a ), diffusive shadows with increased density in the right lower lung and the left middle lower lung; hilum enlarged and blurry; the upper bound of diaphragm covered.By chest X-ray on Nov. 26th, 2009 ( Fig. 11 .93b ), diffusive shadows with increased density in both lungs; hilum enlarged and blurry; the upper bound of diaphragm covered; obviously progressive conditions compared to chest X-ray fi ndings on Nov. 25th, 2009.By chest X-ray on Nov. 27th, 2009 ( Fig. 11 .93c ), diffusive shadows with increased density in both lungs; History of Present Illness . A 22-years-old man, complained of fever and cough for 6 days, with expectoration of a little whitish sputum, nasal obstruction and runny nose. He received therapies for cold in another hospital, with poor outcomes. He was hospitalized on the third after disease onset due to positive throat swabs.Past History . History of intelligence disturbance. Contact History . Self reported none de fi nitive history of contacting with In fl uenza A (H1N1) patients.Signs . Body temperature 38.6 °C. Pharyngeal congestion. Tonsils swollen to I degree. Shortness of breath. The respiration sound of both lungs coarse. Large amount of dry and moist rales in both lungs.Laboratory History of Present Illness . A 42-years-old man, complained of fever and cough for 8 days; chest distress for 5 days. He had fever 8 days ago, with the highest body temperature of 39.5 °C. He also had cough, with whitish sputum but no chills and convulsion. Therapies (details unknown) were given in the local hospital, but with no favorable outcomes. And the patient suffered from chest distress 5 days ago, deteriorating after activities. He was admitted on the seventh day after the disease onset into You'an Hospital in Beijing due to positive throat swabs. Past History . None related to the present illness. Contact History . No de fi nitive history of contacting with In fl uenza A (H1N1) patients.Signs . Body temperature 37.8 °C. Heart rate 86 beats/ min. Breathing rate 32 times/min. Conscious but poor spirituality. Lips cyanosis. Pharyngeal congestion. Tonsils swollen to I degree. The respiration sound of both lungs coarse, with moist rales.Laboratory Sputum culture for 48 h found no pathogens. Diagnostic Imaging By chest X-ray on Dec. 1st, 2009 (Fig. 11.97a ) , cloud mist liked shadows with increased density in both lungs, especially in the right lung; enlarged and thickened hilum.By chest X-ray on Dec. 1st, 2009 (Fig. 11 .97b-f ), large fl aky shadows with increased density in both lungs; parenchymal shadows in some pulmonary tissues, especially in the dorsal and the posterior basal segments.Diagnosis . Pneumonia complicating In fl uenza A (H1N1). History of Present Illness . A 36-years-old man, complained of fever and cough for 6 days. He started to have fever 6 days ago, with a body temperature of 39.7 °C, with cough, bloody phlegm, no chills, convulsion, sore throat, nasal obstruction, rhinorrhea, chest pain and diarrhea. Cefodizime, azithromycin and andrographolide were administered in the local hospital, but with no favorable outcomes. He still suffered from out of breath and limited activities. Therapies of gati fl oxacin, vidarabine, aminophylline intravenous drip were given in the First Af fi liated Hospital of Zhengzhou University, but with occurrence of dyspnea, decreased SaO 2 . Noninvasive mechanical ventilation was then ordered. On the sixth day after illness onset, he was transferred to You'an Hospital in Beijing by an ambulance due to positive throat swabs. Finally, death occurred, followed by autopsy.Past History . None related to the present illness. On Nov. 21st, 2009, the sputum smear found no fungus.On Nov. 21st, 2009, routine blood tests found leukocytes count 5.41 × 10 9 /L, neutrophils 87.84 %, lymphocytes 8.14 %, erythrocytes count 3.94 × 10 12 /L, hemoglobin 112 g/L, platelets count 213 × 10 9 /L. On Dec. 2nd, 2009, blood biochemistry of the liver function found ALT 20 U/L, AST 48 U/L; of renal function found BUN 2.7 mmol/L, Cr 57 m mol/L, UA 135 m mol/L; of electrolytes found K + 3.48 mmol/L, Ca 2+

History of Present Illness . A 74-years-old man, complained of fever an cough for 4 days.Past History . History of hypertension for 8 years, with the highest blood pressure of 200/100 mmHg and a usual blood pressure of 180/90 mmHg. Oral intake of Bezoar antihypertensive pill maintained the blood pressure normal. In addition, a history of type II diabetes for 2 years, with oral intake of metformin but no monitoring of blood glucose. Also having history of chronic bronchitis for more than 10 years. Death occurred with autopsy.Contact History . None.Signs . Body temperature 39.4 °C. Confused in deep coma. No response to verbal commands. Heart rate 120 beats/min and the pulses regular. Breathing rate 24 times/min. Respiration assisted with tracheal cannulation and a respirator. The respiration sound of both lungs low. Rare moist rales in the bottoms of both lungs. Abdomen (−). Both lower extremities not swollen.Laboratory Tests By throat swabs, nucleic acid of In fl uenza A (H1N1) virus positive.On Dec. 3rd, 2009, routine blood tests found leukocytes count 9.51 × 10 9 /L, neutrophils 80.6 %, Hb 102 g/L, platelets count 154 × 10 9 /L. Blood gas analysis found pH 7.3, PaO 2 144 mmHg, PaCO 2 70 mmHg, Diagnostic Imaging By chest X-ray ( Fig. 11.102a, b ) , cloud mist liked blurry shadows with increased density in the both upper lungs and in the both lower lungs; enlarged and blurry hilum.Pathological Analysis Figure 11 .102c-j demonstrated widened pulmonary interstitial, interalveolar fi brosis, in fl ammatory cells in fi ltration (mainly neutrophils), exudation of mononuclear cells, lymphocytes and macrophages by H&E staining. Figure 11 .102k, l demonstrated myocardial interstitial edema and minor blood vessels dilatation by H&E staining. History of Present Illness . A 55-years-old woman, complained of cough for 7 days, fever for 6 days, with the highest temperature of 40 °C. She had no chills, but sore throat, shortness of breath, headache, spasmodic breathing, pink foamy phlegm. Death occurred with following autopsy Past History . None. Contact History . Denied history of contacting with any In fl uenza A (H1N1) patient.Signs . Pharyngeal congestion. Tonsils not swollen. Moist rales in both lungs.Laboratory On Oct. 28th, 2009, routine blood tests found leukocytes count 7.8 × 10 9 /L, neutrophils 88.4 %, lymphocytes 8.2 %. Blood gas analysis found pH 7.512, PaO 2 48.8 mmHg, PaCO 2 32.16 mmHg. The liver functions tests found ALT 166.8 IU/L, AST 270.5 IU/L.Diagnostic Imaging By chest X-ray (Fig. 11.103a ), fl aky shadows with increased density in both lungs, especially in the both lower lungs; enlarged and blurry hilum.By chest X-ray ( Fig. 11.103b ) , fl aky shadows with increased density in both lungs, especially in the right lower lung and the left lung; enlarged and blurry hilum.

By H&E staining (Fig. 11.103c ) , interalveolar walls space widened; alveolar wall congestion; in fi ltration of neutrophils and plasma cells (mainly mononuclear cells); intraalveolar edema and cellulose exudates by H&E staining.By H&E staining (Fig. 11.103d ) , hyaline membrane formed in the alveoli.By H&E staining (Fig. 11.103e ), alveolar epithelium detached; cellulose in some alveolar cavities exudates.By H&E staining (Fig. 11.103f ) , large amount of hyaline membrane formed in the alveoli.By H&E staining (Fig. 11.103g ), blood vessels in alveolar wall congestion.By H&E staining (Fig. 11.103h ), more intraalveolar cellulose exudates.By H&E staining (Fig. 11.103i ), thin alveolar walls; occlusion of blood vessels in the alveolar walls; large number of intraalveolar cellulose exudates.By H&E staining (Fig. 11.103j ), type I epithelial cells detached and necrotic, with following type II epithelial cells slightly proliferate.By H&E staining (Fig. 11.103k ) , intraalveolar loose cellulose exudates.By H&E staining (Fig. 11.103l ) , intraalveolar dense cellulose exudates.By Masson's staining (Fig. 11.103m ), large number of intraalveolar cellulose exudates, with no growth of bacteria.By PAS staining (Fig. 11.103n ), large number of intraalveolar cellulose exudates.By P immunohistochemical staining (Fig. 11.103o ), large number of macrophages gather and clump.By AFB staining (Fig. 11.103q ), large numbers of in fl ammatory cells in fi ltration but with no acid-fast bacilli.

History of Present Illness . A 48-years-old man, complained of fever for 5 days, with the highest temperature of 39 °C. He also had expectoration of yellowish phlegm, spasmodic breathing and chest distress. Death occurred with following autopsy.Past History . Histories of diabetes, chronic renal dysfunction, chronic bronchitis.Contact History . Self reported no history of contacting with any In fl uenza A (H1N1) patient.Signs . Pharyngeal congestion. Tonsils swollen to I degree. On Dec. 12th, 2009, blood gas analysis found pH 7.19, PaCO 2 47 mmHg, PaO 2 168 mmHg. Routine blood tests found leukocytes count 11.51 × 10 9 /L. Blood biochemistry found UREA 32.06 mmol/L, Cr 813.5 m mol/L, Cr 813.5 m mol/L, K + 7.76 mmol/L, Na + 130 mmol/L.Diagnosis . Critical pneumonia complicating In fl uenza A (H1N1).Pathological Analysis By H&E staining ( Fig. 11.104a, b ) , capillary edema and congestion; in fl ammatory cells in fi ltration.By H&E staining ( Fig. 11 .104c, d ), large number of in fl ammatory cells in fi ltration in the myocardial tissues. History of Present Illness . A 45-years-old woman, complained of chills and fever for 5 days, with the highest temperature of 39.5 °C. She also suffered from eyes upsets, dry cough, a little phlegm, chest distress and suffocation. He was diagnosed as having bronchitis in another hospital and received therapies of anti-in fl ammation, but with outcomes of chest distress, shortness of breath. He was then transferred to You'an Hospital in Beijing for treatment, but occurrence of death due to respiratory failure.Past History . Denied histories of major basic diseases. Contact History . Denied history of contacting with any de fi nitively diagnosed In fl uenza A (H1N1) patient or patients with fl u liked symptoms.Signs . Pharyngeal congestion. Body temperature 39 °C. On Nov. 13th, 2009, blood gas analysis found pH 7.466, PaCO 2 35.5 mmHg, PaO 2 76.0 mmHg; routine blood tests found leukocytes count 2.84 × 10 9 /L, neutrophils 83.8 %, lymphocytes 12 %.On Nov. 14th, 2009, blood gas analysis found pH 7.471, PaCO 2 31.8 mmHg, PaO 2 43.6 mmHg; routine blood tests found leukocytes count 3.39 × 10 9 /L, neutrophils 81.1 %, lymphocytes 14.5 %; liver functions tests found ALT 21.1 U/L, AST 51.3 U/L, UREA 3.34 mmol/L, CREA 41.0 m mol/L. On Nov. 15th, 2009, blood gas analysis found pH 7.438, PaCO 2 36.5 mmHg, PaO 2 69.3 mmHg; routine blood tests found leukocytes count 2.18 × 10 9 /L, neutrophils 84 %, lymphocytes 12.8 %.On Nov. 18th, 2009, blood gas analysis found pH 7.488, PaCO 2 33.2 mmHg, PaO 2 46.9 mmHg; routine blood tests found leukocytes count 3.69 × 10 9 /L, neutrophils 67.7 %, lymphocytes 24.7 %; liver functions tests found ALT 62.9 U/L, AST 144.4 U/L, CREA 46.3 m mol/L, Glu 7.45.On Nov. 20th, 2009, blood gas analysis found pH 7.460, PaCO 2 34 mmHg, PaO 2 79 mmHg; routine blood tests found leukocytes count 9.8 × 10 9 /L, neutrophils 82.6 %, lymphocytes 9.4 %, erythrocytes count 3.23 × 10 12 /L, Hb 102 g/L; liver functions tests found ALT 257.4 U/L, AST 91.5 U/L, UREA 8.12 mmol/L, CREA 51.4 m mol/L.On Nov. 30th, 2009, blood gas analysis found pH 7.310, PaCO 2 58 mmHg, PaO 2 78 mmHg; routine blood tests found leukocytes count 11.25 × 10 9 /L, neutrophils 83.5 %, lymphocytes 11.8 %, Hb 102 g/L; liver functions tests found ALT 44 U/L, AST 149 U/L, UREA 4.83 mmol/L, CREA 33.5 m mol/L. Diagnostic Imaging By chest X-ray on Nov. 16th, 2009 (Fig. 11.105a ) , diffusive large fl aky shadows with increased density in both middle lower lungs; boundaries blurry.By chest X-ray on Nov. 27th, 2009 (Fig. 11.105b ), diffusive large fl aky shadows with increased density in both middle lower lungs, decreased transparency of both lungs and progressive conditions compared to chest X-ray fi ndings on Nov. 16th, 2009.By chest X-ray on Dec. 4th, 2009 (Fig. 11.105c ) , diffusive shadows with increased density in both lungs; decreased transparency of both lungs; hilum blurry; progressive conditions compared to chest X-ray fi ndings on Nov. 27th, 2009.By chest X-ray on Dec. 18th, 2009 (Fig. 11.105d ) , diffusive shadows with increased density in both lungs; thickened shadows, parenchymal changes and improved transparency of both pulmonary apex compared to X-ray fi ndings on Dec. 4th, 2009.By chest X-ray on Dec. 19th, 2009 ( Fig. 11 .105e ), diffusive shadows with increased density in both lungs; improved transparency of the left lung compared to the chest X-ray fi ndings on Dec. 4th, 2009.By chest X-ray on Dec. 20th, 2009 (Fig. 11.105f ), diffusive shadows with increased density in both lungs; parenchymal lung tissues fi brosis.By chest CT scanning 72 h after death on Dec. 26th, 2009 ( Fig. 11.105g-j ) , large amount of effusion in bilat-