New York autopsies show 2009 H1N1 influenza virus damages entire airway (like 1918, 1957)

In fatal cases of 2009 H1N1 influenza, the virus can damage cells throughout the respiratory airway, much like the viruses that caused the 1918 and 1957 influenza pandemics, report researchers from the National Institutes of Health (NIH) and the New York City Office of Chief Medical Examiner. The scientists reviewed autopsy reports, hospital records and other clinical data from 34 people who died of 2009 H1N1 influenza infection between May 15 and July 9, 2009. All but two of the deaths occurred in New York City. A microscopic examination of tissues throughout the airways revealed that the virus caused damage primarily to the upper airway—the trachea and bronchial tubes—but tissue damage in the lower airway, including deep in the lungs, was present as well. Evidence of secondary bacterial infection was seen in more than half of the victims.

The team was led by James R. Gill, M.D., of the New York City Office of Chief Medical Examiner and New York University School of Medicine, and Jeffery K. Taubenberger, M.D., Ph.D., of the National Institute of Allergy and Infectious Diseases (NIAID) at NIH. The findings are reported in the Archives of Pathology & Laboratory Medicine, now available online and scheduled to appear in the February 2010 print issue.

"This study provides clinicians with a clear and detailed picture of the disease caused by 2009 H1N1 influenza virus that will help inform patient management," says NIAID Director Anthony S. Fauci, M.D. "In fatal cases of 2009 H1N1 influenza, it appears the novel pandemic influenza virus produces pulmonary damage that looks very much like that seen in earlier influenza pandemics."

The new report also underscores the impact 2009 H1N1 influenza is having on younger people. While most deaths from seasonal influenza occur in adults over 65 years old, deaths from 2009 H1N1 influenza occur predominately among younger people. The majority of deaths (62 percent) in the 34 cases studied were among those 25 to 49 years old; two infants were also among the fatal cases.

Ninety-one percent of those autopsied had underlying medical conditions, such as heart disease or respiratory disease, including asthma, before becoming ill with 2009 H1N1 influenza. Seventy-two percent of the adults and adolescents who died were obese. This finding agrees with earlier reports, based on hospital records, linking obesity with an increased risk of death from 2009 H1N1 influenza.

The researchers examined tissue samples from the 34 deceased individuals to assess how 2009 H1N1 influenza virus damaged various parts of the respiratory system. "We saw a spectrum of damage to tissue in both the upper and lower respiratory tracts," says Dr. Taubenberger. In all cases, the uppermost regions of the respiratory tract—the trachea and bronchial tubes—were inflamed, with severe damage in some cases. In 18 cases, evidence of damage lower down in the finer branches of the bronchial tubes, or bronchioles, was noted. In 25 cases, the researchers found damage to the small globular air sacs, or alveoli, of the lungs.

"This pattern of pathology in the airway tissues is similar to that reported in autopsy findings of victims of both the 1918 and 1957 influenza pandemics," notes Dr. Taubenberger.

The researchers also examined 33 of the 34 cases for evidence of pulmonary bacterial infections. Of these cases, 18 (55 percent) were positive for such infections. Not all of those individuals who had bacterial pneumonia along with 2009 H1N1 virus infection had been hospitalized, however, indicating that some had acquired their bacterial infections outside of a health-care setting. This raises the possibility, say the authors, that community-acquired bacterial pneumonia is playing a role in the current pandemic. "Even in an era of widespread and early antibiotic use," write the authors, "bacterial pneumonia remains an important factor for severe or fatal influenza."

Computerized tomography (CT) lung images were available in four cases of pulmonary bacterial infection. In all four cases, the CT scans showed an abnormality known as ground-glass opacity, which are patches of rounded haze not seen in normal lung images. It is not known, say the researchers, whether the abnormalities detected by CT in the four cases also occur in people who have milder H1N1 infections. They call for additional investigation into the utility of CT scans as a tool to help clinicians identify and better treat severe H1N1 infections.

Visit www.flu.gov for one-stop access to U.S. government information on avian and pandemic influenza. Also, visit NIAID's flu Web portal at http://www3.niaid.nih.gov/topics/Flu/.

NIAID conducts and supports research—at NIH, throughout the United States, and worldwide—to study the causes of infectious and immune-mediated diseases, and to develop better means of preventing, diagnosing and treating these illnesses. News releases, fact sheets and other NIAID-related materials are available on the NIAID Web site at http://www.niaid.nih.gov .

The National Institutes of Health (NIH)—The Nation's Medical Research Agency—includes 27 Institutes and Centers and is a component of the U. S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments and cures for both common and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.

Reference: JR Gill et al. Pulmonary pathological findings of fatal 2009 pandemic influenza A/H1N1 viral infections. Archives of Pathology & Laboratory Medicine. Published online Dec. 7, 2009. {Note: Full text of the paper is available at www.archivesofpathology.org}

Staph, Strep and even Gram negative organisms aren’t opportunistic. They are considered secondary bacterial infections. Lungs are infected with virus and natural defense mechanisms such as the mucociliary apparatus is overwhelmed allowing bacterial invasion.

I agree with you that “opportunistic” implies a loss of humoral or cell mediated immunity in the body due to bone marrow suppression, HIV or severe immune deficiency. Those organisms are typically fungi, protozoa or other viruses like CMV.

Hmmm...the article says the bacterial infections were secondary and I said opportunistic. Any chance that some coccus was there first to make the viral infection worse?

Nah it sure isn’t the flu. But the stuff going around norCal seems to hang on and drag on. Not enough to keep you in bed feeling like death warmed over and yet not minor enough to ignore completely. My mom always said that winter was a good time for chicken soup and ginger ale. I believe those to be the panacea for all known winter illnesses. ( well most all anyway)

I had and still have (some of) the following: fever of 100.5 for only two days early on, horrible sore throat, bad cough (more in throat than chest), bacterial conjunctivitis in both eyes, cold/sinus symptoms coming after the bronchitis was diagnosed. This was odd because the order of symptoms was reversed from what I am used to.

Doc is certain this was not H1N1 and I would agree — I never had the bad chills or any high fever or other hallmarks of a flu. I never had a problem getting out of bed, did not have the awful fatigue flu causes. I’ve had flus, and this was some weird combo of other things, not flu.

Doc said they are seeing many flu cases in their office but that’s not my problem. He told me to come back when I am over this and get a swine flu shot as they have the vaccine. Maybe I will and maybe I won’t — I’m above the age where flu is common and hear it is on the wane now anyway.

Re: “Nah it sure isn’t the flu. But the stuff going around norCal seems to hang on and drag on. Not enough to keep you in bed feeling like death warmed over and yet not minor enough to ignore completely. My mom always said that winter was a good time for chicken soup and ginger ale. I believe those to be the panacea for all known winter illnesses. ( well most all anyway)”

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Agree — I feel the way you describe — felt awful and could not sleep at night due to cough and horrible throat pain but was much better during the day — enough to sit at PC almost nonstop ;) With flu, most people can barely get out of bed.

I agree with your mom, too, re ginger ale and soup for these problems. Had some chicken soup yesterday and it really cleared out the sinuses (from the steam). Breathing steam is right up there with ginger ale and soup.

My friend’s child and my friend both tested postive for H1N1 .

My friend is a nurse and she had a bad sore throat , a deep deep cough , and chest congestion she had no fever , no aches , nor was extra tired etc...

Her daughter had a fever , sore throat , itchy red eyes , and a bad dry cough . Her daughter got bronchitis but still tested postive for H1N1.

They both had different symptoms but both did test postive for H1N1 .

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