Postcard from Latin America #4

Dr. Richard Wenzel writes from Chile:

Made rounds in the adult and peds ICU of one of the university hospitals- hospital clinico UC. They nodded concurrence that about one-third of non-icu admissions have no fever. More interesting they volunteered that half of the outpatients with H1N1 confirmed had no fever. Each had anecdotes that they have screened patients with rhinorrhea only and confirmed H1N1. The point is that the clinical expression of H1N1 is extremely broad. Obviously screening patients with fever will miss many. Lastly, for counting patients, if fever is part of the case definition, the denominator will be greatly underestimated.

The adult in the ICU was an obese 34 year old man whose weight was 150 Kg and BMI was 40. Obesity was recognized informally in Mexico City when I was there earlier. The recent MMWR notes obesity as well. Obviously the question is whether the weight per se is an issue, and maybe these patients have no reserve when they get viral pneumonia. However, I suspect that insulin resistance is a factor: many have underlying hypertension and diabetes (i.e., metabolic syndrome).

Of interest is how H1N1 is managed in Chile vs Brazil. Here clinicians make a clinical diagnosis- confirmation is not essential - and order oseltamivir. The drug is given to patients free of charge.