To the Editor,
During the season 2013–2014, Greece suffered an influenza epidemic that resulted in 145 fatalities [Citation1]. We retrospectively analyzed patients with cancer who were infected with influenza and hospitalized in our intensive care unit (ICU) from September 2013 to June 2014. Our department is a six-bed ICU in a cancer hospital. Diagnosis was based on an influenza-like clinical syndrome along with a positive real time RT-PCR testing of oropharyngeal swab for influenza virus.
Six patients, four women and two men, 26–71 years old (median age 53.5), fulfilled our criteria (Supplementary Table I, available online at http://informahealthcare.com/doi/abs/10.3109/0284186X.2014.974830). Two patients suffered from multiple myeloma, one of whom had autologous stem cell transplantation five years ago, but had subsequently relapsed. Four patients had solid tumors – one had breast cancer, one ovarian cancer and two had sarcoma. Three of the patients with solid tumors had metastatic disease. All patients received chemotherapy within three weeks prior to ICU admission and one with sarcoma received additionally autologous stem cell transplantation. Notably, none of the patients had been vaccinated for the seasonal flu. Upon admission all patients had a ratio of PaO2/FiO2 < 100 with bilateral infiltrations on chest x-ray and two patients were neutropenic. All patients received oseltamivir >48 h after their symptoms began. All had positive oropharyngeal swab for H1N1pdm09 and received care with invasive mechanical ventilation, antibiotic coverage, vasopressors and/or inotrops, and four patients received steroids. Oseltamivir was prescribed at a dose of 75mg q12h for all patients and two had their dose increased to 150mg q12h. Length of stay in the ICU ranged from 2 to 45 days (median 5 days). Thirty-day mortality was 83.3% (5 patients) and ICU mortality was 100%. All patients died from respiratory tract infection and multiple organ failure. Three patients suffered superinfection, two of those had transient clinical improvement and died after 45 and 17 days, respectively. The patient that died after 45 days, while on clinical improvement, managed to receive chemotherapy (bortezomide and dexamethasone) for multiple myeloma. One patient was bacteremic since eight days prior to his admission and died on his second day in the ICU despite receiving directed antibiotic treatment.
Among our critically ill cancer patients infected with influenza, no one survived to discharge. Other authors have also published mortality rates up to 100% [Citation2,Citation3] in similar populations that required invasive mechanical ventilation. Alarmingly, none of the patients was vaccinated for seasonal influenza and all received delayed oseltamivir treatment. Current guidelines recommend vaccination for all adult cancer patients, except those receiving anti-B-cell antibodies or intensive chemotherapy, since these two patient categories cannot mount an adequate serologic response [Citation4,Citation5]. Thus, consideration of influenza vaccination should accompany cancer diagnosis and antecede immunosuppressive treatment if feasible. From the few available data, vaccination rates for influenza in Greece are not high and for this, misconceptions about the gravity of influenza and the safety of vaccination have been implicated [Citation6,Citation7]. Additionally during the year 2013–2014 in Greece there was a shortage of vaccines substantial enough to shift guidance towards early use of antiviral drugs [Citation8]. We cannot emphasize strongly enough that timely vaccination and targeted information on influenza prevention and treatment may prevent future fatalities in cancer patients.
Supplementary material available online
Supplementary Table I available online at http://informahealthcare.com/doi/abs/10.3109/0284186X.2014.974830.
ionc_a_974830_sm6179.pdf
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We are grateful to Dr Anastasios Grivas (Metaxa Hospital, Greece), Dr Christos Pleros (Chania General Hospital St George) and Dr. Anastasia Tikhonova (New York University, USA) for critical reading of the manuscript. Also we would like to thank the medical team that cared for the patients. We would like to especially thank the nursing stuff for their efforts to provide optimal care to the patients and at the same time make the ICU a friendly environment.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
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