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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 22-25

When COVID rules…. Severe acute respiratory illness due to another virus

1 Department of Critical Care Medicine, Baby Memorial Hospital, Kozhikode, Kerala, India
2 Department of Pulmonary Medicine, Baby Memorial Hospital, Kozhikode, Kerala, India

Date of Submission20-Jul-2021
Date of Decision21-Sep-2021
Date of Acceptance21-Sep-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Rayees Kathim
Rashmilas, Tower Stop, Edayannur P.O, Chalode, Kannur - 670 595, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_18_21

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This is a case of a 49-year-old male alcoholic who developed severe breathlessness, desaturation, and loss of consciousness following an alcoholic bout. Due to the ongoing COVID pandemic, he was suspected to be having COVID-19 infection. His clinical and radiological presentations were atypical for COVID-19. On investigations, it was found to be due to another rare viral pneumonia. The case is being reported due to its rarity.

Keywords: Coronavirus, influenza, viral pneumonia

How to cite this article:
Kathim R, Gangaprasad G, Kumar A, Chetambath R. When COVID rules…. Severe acute respiratory illness due to another virus. J Adv Lung Health 2022;2:22-5

How to cite this URL:
Kathim R, Gangaprasad G, Kumar A, Chetambath R. When COVID rules…. Severe acute respiratory illness due to another virus. J Adv Lung Health [serial online] 2022 [cited 2022 May 16];2:22-5. Available from: http://www.jalh.com/text.asp?2022/2/1/22/335922

  Introduction Top

When the world is in the middle of a life-threatening viral pandemic due to SARS CoV-2, the occurrence of other viral infections get less attention. Influenza viral infections are so frequent in the community, especially during the winter season. Even though the majority develops asymptomatic or self-limiting infections, rarely fatal pneumonia and acute respiratory distress syndrome (ARDS) may also develop. During the present COVID pandemic, severe influenza viral infections are considered only when repeated samples become negative for COVID-19. Here, we present a case of severe pneumonia and ARDS due to the Influenza B virus which was diagnosed and effectively treated.

  Case Report Top

A 49-year-old male patient presented with sudden onset of breathlessness and altered sensorium. Patient was obese with no history of hypertension or diabetes. He was an alcoholic with occasional bingeing, and the present episode occurred after a binge drinking. There was no history of fever, chest pain, vomiting, or diarrhea. He was unconscious when he reached the emergency department with an oxygen saturation of <78%, blood pressure of 140/90, and heart rate of 100 beats/m. He had a Glasgow Coma Scale of 7/15. ABG showed severe hypoxemia satisfying ARDS criteria. He was immediately intubated and ventilated. In the present pandemic scenario, he was tested for COVID-19 and it turned out to be negative. Laboratory picture showed increased total counts (27,500), mild thrombocytopenia (128,000), renal functions were normal, liver function showed mild transaminitis and raised inflammatory markers [Table 1]. Chest X-ray showed right-sided infiltrates with central predominance and peripheral sparing [Figure 1]. A possibility of aspiration pneumonia was considered. He was started on broad-spectrum antibiotics along with atypical coverage and other supportive measures. Bronchoscopy and bronchoalveolar lavage were done, which did not show any food particles but had an exudative picture. The sample was sent for bacterial, fungal cultures, and the viral panel, which was found to be influenza B positive. He was immediately started on oseltamivir and showed dramatic improvement clinically and radiologically [Figure 2]. He became hemodynamically and clinically stable and was slowly weaned off the ventilator. He was discharged after 6 days with no complications.
Table 1: The investigation results of the patient

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Figure 1: X-ray chest at the time of admission showing bilateral alveolar infiltrates more on the right side. Lesions are oriented towards the midline sparing peripheral and basal regions

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Figure 2: X-ray chest taken after 6 days shows near resolution of opacities

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  Discussion Top

Influenza is an infectious disease which causes significant morbidity and mortality. It is a disease caused by influenza viruses which has a sudden onset, causes respiratory tract infection with fever, and generally limits by itself. However, it may also lead to ARDS, meningitis, encephalitis, and similar life-threatening severe clinical conditions.

There are four types of influenza viruses: A, B, C, and D. Human influenza A and B viruses cause seasonal epidemics of disease (known as the flu season) almost every winter [Figure 3]. Influenza A viruses are the only influenza viruses known to cause flu pandemics, i.e., global epidemics of flu disease. Influenza B viruses are usually typified into two lineages (B/Yamagata and B/Victoria), and subtypes are not named. Influenza type C infections generally cause mild illness and are not thought to cause human flu epidemics. Influenza D viruses primarily affect cattle and are not known to infect people or cause disease in them.[1]
Figure 3: Human seasonal influenza viruses

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The influenza virus has caused recurrent epidemics of acute febrile syndrome every 1–4 years for at least the recent centuries. The first epidemic report of an influenza-like illness was noted in 1173–1174,[2] but the first definitive epidemic was reported in 1694.[3] Currently, the most important and efficient drug for severe influenza infections is oseltamivir. With the initiation of this drug, especially in the first 2 days, severe influenza infections can be brought under control, and prevention of related deaths may be achieved.[4]

During the last pandemic wave, neuraminidase inhibitors (NAIs) – primarily oseltamivir and zanamivir – were widely prescribed for patients with confirmed or suspected A H1N1pdm09 infection.[5],[6]

Compared to Influenza A infection, influenza B causes mild, self-limiting disease, but rarely severe life-threatening pneumonia is also reported. Patients with influenza typically experience the most severe symptoms during the 1st week of illness, whereas patients with COVID-19 may experience a longer duration of symptoms with a peak during the 2nd or 3rd week of illness. Our patient had clinical and radiological presentations different from that of typical COVID-19 pneumonia [Table 2]. The patient developed severe pneumonia with respiratory failure on the 1st day of onset. X-ray showed alveolar shadows predominantly on the right side, sparing the peripheral and basal region. COVID-19 pneumonia usually presents with peripheral and basal lesions. The patient responded to oseltamivir which is unlikely in COVID infections.
Table 2: Comparison between seasonal influenza and SARS CoV-2 (Courtesy Solomon D A et al.[3])

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Oseltamivir (Ro 64-0796) is the orally bioavailable ethyl ester prodrug of Ro 64-0802, a potent and selective inhibitor of influenza neuraminidase in vitro.[7] Oseltamivir is the first orally administered NAI with demonstrated efficacy in the treatment of naturally acquired influenza in humans.[8] Orally administered oseltamivir protects against experimental influenza in animals and humans.[9],[10],[11] Daily administration of one 75 mg capsule for 6 weeks was effective and well tolerated in preventing influenza during a seasonal outbreak.[12]

  Conclusion Top

Despite the rapid advances in the areas of SARS-CoV-2 diagnostics, treatment, and vaccine development, the population remains vulnerable to concurrent influenza and COVID-19 epidemics. Although no specific clinical manifestations reliably distinguish between early influenza disease and COVID-19, it will be important to identify the viral etiology in clinical practice. First, the management and approach to both viruses are different. Influenza can be treated with a NAI or a Cap-dependent endonuclease inhibitor, neither of which have antiviral activity against SARS-CoV-2. The syndrome caused by each virus follows a different course. Physicians and other health-care professionals should be aware of these situations and remain flexible in the approach to diagnosis during these times of unprecedented challenges.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


  References Top

http://cdc.gov/flu/viruses.types.html. last reviewed: September 23, 2021 Content source: Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD).  Back to cited text no. 1
Hirsch A. Hand book of Geographical and Historical Pathology. Publisher London New Sydenham Society, 7st Ed.1883-86;1:7  Back to cited text no. 2
Molineux D. Dr Molineux's. Historical Account of the Late General Coughs and Colds; with Some Observations on Other Epidemic Distempers. Philos Trans. 1683-1775; 1694:105-11.  Back to cited text no. 3
Subbarao K. Influenza viruses. In: Long SS, Pickering LK, Prober CG, editors. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Crossre: Churchill, Livingstone; 2009. p. 1130-8.  Back to cited text no. 4
Muthuri SG, Venkatesan S, Myles PR, Leonardi-Bee J, Al Khuwaitir TS, Al Mamun A, et al. Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: A meta-analysis of individual participant data. Lancet Respir Med 2014;2:395-404.  Back to cited text no. 5
Gasparini R, Amicizia D, Lai PL, Bragazzi NL, Panatto D. Compounds with anti-influenza activity: Present and future of strategies for the optimal treatment and management of influenza. Part I: Influenza life-cycle and currently available drugs. J Prev Med Hyg 2014;55:69-85.  Back to cited text no. 6
Kim CU, Lew W, Williams MA, Liu H, Zhang L, Swaminathan S, et al. Influenza neuraminidase inhibitors possessing a novel hydrophobic interaction in the enzyme active site: Design, synthesis, and structural analysis of carbocyclic sialic acid analogues with potent anti-influenza activity. J Am Chem Soc 1997;119:681-90.  Back to cited text no. 7
Treanor JJ, Hayden FG, Vrooman PS, Barbarash R, Bettis R, Riff D, et al. Efficacy and safety of the oral neuraminidase inhibitor oseltamivir in treating acute influenza: A randomized controlled trial. US Oral Neuraminidase Study Group. JAMA 2000;283:1016-24.  Back to cited text no. 8
Mendel DB, Tai CY, Escarpe PA, Li W, Sidwell RW, Huffman JH, et al. Oral administration of a prodrug of the influenza virus neuraminidase inhibitor GS 4071 protects mice and ferrets against influenza infection. Antimicrob Agents Chemother 1998;42:640-6.  Back to cited text no. 9
Sidwell RW, Huffman JH, Barnard DL, Bailey KW, Wong MH, Morrison A, et al. Inhibition of influenza virus infections in mice by GS4104, an orally effective influenza virus neuraminidase inhibitor. Antiviral Res 1998;37:107-20.  Back to cited text no. 10
Hayden FG, Treanor JJ, Fritz RS, Lobo M, Betts RF, Miller M, et al. Use of the oral neuraminidase inhibitor oseltamivir in experimental human influenza: Randomized controlled trials for prevention and treatment. JAMA 1999;282:1240-6.  Back to cited text no. 11
Hayden FG, Atmar RL, Schilling M, Johnson C, Poretz D, Paar D, et al. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza. N Engl J Med 1999;341:1336-43.  Back to cited text no. 12
Soloman DA, Sherman AC, Kanjilal S. Influenza in the COVID-19 era. JAMA 2020;324:1342-3.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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