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Indian Journal of Medical Sciences, Vol. 64, No. 12, December, 2010, pp. 552-555 Case Report 2009H1N1 Infection in a 1-day-old neonate Chhaya Valvi, Rajesh Kulkarni, Aarti Kinikar, Sandhya Khadse Department of Pediatrics, B.J. Medical College and Sassoon General Hospital, Pune, Maharashtra, India Correspondence Address: Code Number: ms10004 PMID: 21258158 DOI: 10.4103/0019-5359.75930 Abstract A full-term female neonate was delivered with meconium stained amniotic fluid by cesarean section by a 2009H1N1 positive 22-year-old second gravida mother, who developed symptoms 8 days prior to delivery. The neonate was completely and immediately isolated from the mother after delivery. Oseltamivir was started at birth to the neonate who had a potential possibility of 2009H1N1 infection. At 5 hours of life, the neonate developed respiratory distress. The neonate's throat swab sent for 2009H1N1 by real-time polymerase chain reaction (RT-PCR) assay was positive. The neonate required oxygen by hood for 3 days and made an uneventful recovery. The mother developed acute respiratory distress syndrome after delivery, requiring ventilatory care for 14 days and was discharged after 25 days stay in hospital. 2009H1N1 infection, although rare, needs a high index of suspicion and prompt therapy in neonates. Clinicians should be alert about the possibility of perinatal transmission of 2009H1N1.Keywords: 2009H1N1 infection, breast feeding, newborn, pregnancy, oseltamivir Introduction Evidence from the previous pandemics suggests an increased risk for adverse outcomes among infants born to mothers infected with influenza during pregnancy. [1] A large case series of hospitalized pregnant women with H1N1 infection showed that 57% of neonates were admitted to neonatal intensive care unit (NICU). [2] We report a case of 2009H1N1 infection in a newborn whose mother became ill with 2009H1N1 infection during the perinatal period. Review of literature of the several pandemics of influenza reveals that there has been no good documentation of transplacental passage of the virus. The impact of 2009H1N1 on the newborn is unknown, but based on isolated reports, [3],[4] newborns are expected to be at increased risk of severe illness. Case Report A 22-year-old second gravida mother of 38 weeks gestation had fever, cough with white scanty expectoration since 5 days and breathlessness 2 days prior to admission. Antenatal screening for syphilis, hepatitis B and human immunodeficiency virus was negative with uterine ultrasonography on admission showing oligohydraminos. She had a temperature of 37.5°C, pulse 100/min, respiratory rate 30/min, and blood pressure 150/90 mmHg. The fetal heart rate was 144/min. A nonstress test showed normal reactive response. The hemoglobin was 11.4 g%, leukocyte count 6600/mm 3 and platelet count was 140,000/mm 3 . Renal function test and blood sugar were normal. Radiography of the chest revealed bilateral patchy consolidation. Broad spectrum antibiotics were administered intravenously. The mother was in the hospital during the peak of pandemic 2009H1N1. As per the hospital guidelines formulated, throat swab for 2009H1N1 by real-time polymerase chain reaction (RT-PCR) was immediately sent on admission and then oseltamavir 150 mg twice a day was started 5 days after the onset of symptoms. Her throat swab 2009H1N1 by RT-PCR was positive. During the 2-day course in the ward, the mother had mild respiratory distress requiring oxygen by mask maintaining oxygen saturation 92% and pCO2 of 30. Blood pressure increased to 170/100 mmHg; hence, antihypertensive drugs were started. On the third day of admission, fetal distress developed requiring emergency cesarean section which was performed under general anesthesia. Cesarean section was conducted in a separate designated operation theater. The liquor was thick meconium stained. The 2.1 kg female newborn was non vigorous at birth, with Apgar score of 5 at 1 min and 8 at 5 min. Endotracheal and oropharyngeal suction was done. The chest was clear on auscultation after birth. The mother was under general anesthesia and the baby was completely and immediately isolated from the mother after birth. After cesarean section, the mother developed severe respiratory distress requiring intensive cardiopulmonary support and ventilator for the next 14 days. Breast feeding was not initiated at birth. The neonate was administered Syrup oseltamivir (12 mg) 1 ml orally twice a day due to a potential possibility of developing 2009H1N1 infection. The neonate developed respiratory distress at 5 hours of life, requiring transfer to the NICU. The heart rate was 160/min, and the respiratory rate was 68/min, with subcostal recessions and chest clear on auscultation. Oxygen by hood with FiO2 of 50% and intravenous fluids were started. Broad spectrum antibiotics were started to cover sepsis (in view of high risk factors in mother viz. fever 2 days prior to delivery, fetal distress, meconium stained liquor requiring endotracheal suction) pending blood culture results which was later reported negative. Throat swab for 2009H1N1 collected at 5 hours of life was confirmed positive by RT-PCR. Hemogram showed hemoglobin 19.3 g%, leukocyte count 8000/mm 3 and platelet count of 100,000/mm 3 . The neonate maintained oxygen saturation of 92-94%. Chest radiograph [Figure - 1] showed bilateral pulmonary infiltrates. On the second day, the respiratory distress decreased and the neonate was gradually started on formula feeds. Oseltamivir was given for 5 days, which was tolerated well. A repeat RT-PCR done after 5 days of treatment with oseltamavir was negative for 2009H1N1. The neonate was discharged on day 9 of life. Mother was discharged after 25 days stay in hospital with advice to breast feed the neonate. On routine follow-up, mother and neonate remained well. To the best of our knowledge, this is the first report of perinatal transmission of 2009H1N1 infection from India. Discussion Several comments can be given on this case report . Intrauterine infection of the fetus is potentially possible from the maternal influenza viremia and influenza has rarely been detected in vaginal secretions, but it is most likely that the infant will be infected postnatally by the respiratory route. [5] Risk of transmission of 2009H1N1 from mother to fetus is unknown; the newborn should be considered to be potentially infected if delivery occurs during the 2 days before through 7 days after illness onset in the mother. [5] Our patient was likely infected in utero because she was delivered by cesarean section and was never exposed to the mother, who required intensive cardiopulmonary support after delivery. Placental examination for viral studies would have given promising clues regarding route of transmission but was not done in our case, which is the limitation in this case. Suspected transplacental transmission of the 2009H1N1 virus has been reported. [3] Transplacental passage of H3N2 infection has been documented with demonstration of hemagglutinin inhibition antibody titers on cord blood. [6] This analysis was not done in our case. Viremia is rare with influenza virus, [7] although transmission of highly pathogenic strains of influenza virus, avian influenza A (H5N1), across the placenta has been reported. [7] Therefore, the likelihood of virus reaching the uterus and placenta is probably higher in avian influenza than in human influenza [8] but may be a rare possibility in this case. The respiratory distress that developed in the neonate at 5 hours of life may be due to 2009H1N1 infection or wet lung and meconium aspiration. The latter two possibilities were less likely as distress was not present at birth, chest findings were clear on auscultation, with chest radiography showing bilateral pulmonary infiltrates. A repeat throat swab (done as younger age correlates with longer period of viral shedding after the onset of symptoms [9] ) by RT-PCR done after 5 days of treatment with oseltamavir was negative. Data on treatment of newborn infants with 2009H1N1virus infection are limited. However, newborn infants with severe or deteriorating illness should be treated. Oseltamivir 3 mg/kg/dose once daily for 5 days to newborn infants younger than 14 days and 3 mg/kg/dose twice daily for 5 days to newborn infants older than 14 days is recommended. [10] Women can continue breast feeding while following appropriate infection control measures like hand hygiene, use of face mask and observation of respiratory hygiene/cough etiquette guidelines. Newborn babies should be roomed-in with mothers even if the mother has H1N1 infection. This is especially important in developing countries. Currently, there is no evidence that the potential risk of newborn infection with pandemic 2009H1N1 outweighs the risk that would result from separating the baby from the mother and from not being breastfed. [10] Pregnant women merit priority vaccine administration. H1N1 adjuvanted vaccines are safe for pregnant women as recommended by World Health Organization (WHO). [10] 2009H1N1 positive newborns need close monitoring, breast feeding can be encouraged and the infected infants can be treated safely with oseltamivir in recommended doses. References
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