Clinical signs and symptoms

of Viral Infection
and Respiratory Related Diseases

Sumardi
Pulmonary Division
Internal Medicine Departement
GMU School of Medicine
Sardjito General Hospital
 INTRODUCTION
NEW EMERGING DISEASE
HIV/AIDS
BIRD FLU (Influenza A subtype H5N1)
SWINE ORIGIN INFLUENZA INFECTION H1N1 (SOIV)
WILDTYPE POLIO
EBOLA, ETC
HISTORY
influenza virusanimal origin
humans began to domesticate animals infection on
humansearly as 2000 B.C.
Hippocratesepidemic withflu-like symptoms (412 B.C)
Livy in ancient Romesimilar outbreak of a sudden
malady
Types of viral influenza
A,B and C
Subtype depent on
surface antigen
hemaglutinins (H) 16
neuraminidases (N) 9
Spanish Flu type A,
subtype H1N1 (1918)
influenza A (H3N2) virus
pandemic (1968)
Bird Flu type A,
subtype H5N1 (1997)
Viral Transmission
highly contagious viral diseasespread very
efficiently
person-to-personcoughing and sneezing
boarding schools
households
offices
medical settings
cruise ships
nursing homes
prisons
semi-closed or closed populations
Incubation
1-4 days with an average of 2 days
Adultsinfectiousday before symptoms
begin 5 days after illness onset
3050 % of infected personsasymptomatic
Severely immunocompromised persons can
shed virus for weeks or months.
Signs and symptoms

extremely broadasymptomatic infections severe

illness and death
abrupt onset (50-70% of patients)
fever
chills
muscle aches
headache
anorexia
dizziness
sense of fatigue
nonproductive cough
sore throat
runny nose
Signs and symptoms . cont
Respiratory illness caused by influenza is
difficult to distinguish from illness caused by
other respiratory pathogens on the basis of
symptoms alone !!!
Influenza illness typically resolves after a
limited number of days for the majority of
persons, while cough and malaise can persist
for >2 weeks.
Signs and symptoms . cont
Among certain persons, influenza can exacerbate
underlying medical conditions:
Chronic Pulmonary disease
Cardiac disease
Diabetes Mellitus
Malignancy, etc
lead to secondary bacterial pneumonia or primary
influenza viral pneumonia, or occur as part of a co-
infection with other viral or bacterial pathogens
Influenza infection associated with :
encephalopathy, transverse myelitis, Reye syndrome,
myositis, myocarditis, and pericarditis
Risk and Comorbid factor
Risk for persons aged >65 years :
Complications
Hospitalization
Deaths
Increase in mortality generally accompanies
influenza epidemics:
from respiratory illness including pneumonia
also from exacerbation of preexisting
conditions such as heart, lung and kidney
diseases, and bacterial superinfections
Bird Flu
(Influenza A subtype H5N1)
Avian flu infected to human
Increased human habitation near poultry and swine
raising facilities pose greater influenza outbreak risk
combination of environmental factors that may have
contributed to the greatest pandemic of recent times
similar conditions exist throughout Southeast Asia
today
Avian influenza A virus subtype H5N1 can infect
humans to cause a severe viral pneumonia with
mortality rates of more than 30%
Bird Flu: symptoms & signs
Flu like syndromes:
fever
chills
muscle aches
headache
anorexia
dizziness
sense of fatigue
nonproductive cough
sore throat
Severe dyspnea on day 2 3
Asymptomatic about 6%
Bird Flu: pathogenesis
The biological basis for this unusual disease severity
is not fully understood
the major site of H5N1 viral replication in the lung is
the pneumocyte
hyperinduces proinflammatory cytokines, including
tumor necrosis factor alpha (TNF-alpha) Multiple
Organ Dysfuncton Syndrome (MODS)
cytokine storming diffuse alveolar damage
Acute Respiratory Distress Syndromes (ARDS)
Reactive haemophagocytosis was also observed in
the hyperplastic bone marrow and in the parafollicular
areas of the bronchial and hilar lymph nodes
Bird Flu: histopathological changes

Organising diffuse alveolar damage, with

interstitial fibrosis;
hepatic central lobular necrosis (Reyes
syndrome)
acute renal tubular necrosis;
lymphoid depletion.
Viral only in lung
Organ damage by cytokine storming
Bird Flu: Clinical appearance
Flu symptoms
and signs
Severe dyspnea
on day 2 or 3 of
illness
Leucopenia
Lymphopenia
Increase serum
transaminases
Increase serum
BUN & creatinin
BANJARNEGARA CASE of Bird Flu (Okt06)
Chif complaint : dyspnea
Fever, odynophagia, cough 7 days before hospitalization.
Dyspnea 5 days before hospitalization.
Many bird die in a week near home
Bird Flu: Clinical appearance
CXR appearance
Recovery from
Bird Flu
Bird Flu Management.

No effective treatment for Bird Flu, especially

in severe cases
Supportive care: Community Acquired
Pneumonia (CAP), sepsis, MODS
Respiratory support Acute Respiratory
Distress Syndrome (ARDS).
Antiretroviral:
Oseltamivir 75 mg bid
Zanamivir inhalation bid
Ribavirin
Bird Flu pandemic?
Every influenza pandemic since 1850, [other
than the 1918 pandemic] has originated in
China.
With the recent occurrences of the new bird
influenza and the accidental release of the
1957 H2N2 influenza strains to labs, time
may be running short until the next
pandemic
Indonesia local endemic Bird-Flu and
seasonally December to March
 Bird Flu pandemic? plus
HIV/AIDS pandemic?
Every influenza pandemic since 1850, [other
than the 1918 pandemic] has originated in
China.
With the recent occurrences of the new bird
influenza and the accidental release of the 1957
H2N2 influenza strains to labs, time may be
running short until the next pandemic
?KNOW FLU H1N1 PANDEMIC
In the future may pandemic of Flu H1N1 &
HIV/AIDS, and we must preparing for
anticipation
 INFLUENZA H1N1
(SWINE ORIGIN INFLUENZA VIRUS)
(SOIV)

Sumardi
Tim Penanggulangan Flu Burung/Flu H1N1
RSUP Dr. Sardjito
YOGYAKARTA
 WHAT FLU H1N1

INFLUENZA TYPE A SUBTYPE H1N1

FROM MEXICO NORTH AMERICA
FROM PIGS?
FROM HUMAN PIG HUMAN?
MORTALITY <10%
Why Mexico? Well overcrowding, poor
nutrition and overall poor immunity, all
of which are indigenous to Mexico will
radically increase your risk of death
 WHOW?

AIRBORN DISEASE VIA DROPLET/TOUCH

1 MONTH SPREAD to 18 COUNTRIES
 NEW INFLUENZA VIRUS?

MUTATION?
REASSORTMENT?

H1N1 1918?

NEW H1N1 2009?

SEQUENCING? DIFFER 8 PROTEINS

 EVOLUTION VIRUS H1N1?

INTERACTION
PIG/HUMAN/
BIRDS?
 CLINICALLY of Flu H1N1
INFLUENZA LIKE ILLNESS (ILI)
FEVER>380 C
COUGH

ODYNOPHAGY

MYALGIA

CEPHALGIA

MALAISE

NAUSEA,VOMITE,DIARHOE

MAY SEVERE if + COMORBID: DM,

PREGNANT, CVD, COPD, CHILD, CANCER,
ASTHMA, ELDERLY, HEART DISEASE
Suspect Case if ILI+country with epidemic
of H1N1
PNEUMONIA IN FLU H1N1
COMORBID FACTOR
Pneumonia in Flu H1N1
 CASE of ARDS caused by Flu H1N1:
Pregnant Woman, 29 yo H1N1(+) Sleman (die)
 CASE ARDS caused by H1N1 influenza:
Pregnant Woman, 29 yo H1N1(+) Sleman (die)
SYMPTOM :
16 WEEKS PREGNANT
2 DAY FEVER
DAY 3rd COUGH PRIVATE HOSPITAL
DAY 4th DYSPNEA SARDJITO HOSPITAL
4 HOURS AT ER for ARDS VENTILATION
PATIENT DIE ex causa ARDS
HISTORY of MANY PEOPLE FLU IN THE VILLAGE
OTHER CASE: MAN 50 YO+ASTHMA (die)
CASE of MYOCARDITIS+ARYTHMIA: woman 41 yo
H1N1 (+)
 MANAGEMENT of FLU H1N1
STAY AT HOME UNTIL 14th day
USE SURGICAL MASKER DOUBLET or N95
GOOD NUTRITION
DO NOT CONTACT OTHERS
HEALTHY LIFE
HAND WASHING
OSELTAMIVIR 48 HOURS IN INITIAL of FEVER
REFER TO HOSPITAL IF SEVERE or DYSPNEA
PREVENTION: Immunization (oral & injection)
specially child<5 yo;pregnant;HIV
ALHAMDULILLAH

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