Case Study: H1N1 Swine Flu, my influenza experience

Is this really a case study? Okay, it's more of a personal accounting of the twelve days in May of 2009 during which I was suffering from severe respiratory influenza related to the H1N1 Swine Flu.  I documented the course of this illness because it was so weird and prolonged.  I decided to post my experience for the benefit of others going through a bout of H1N1 influenza.

Here's a rundown of my recent illness:

Day 1: Thurs. eve., May 14th. I noticed that tell-tale "tickle" in my chest and the urge to cough deeply. My husband the mailman had brought this upper-respiratory virus home earlier in the week. After four days of body aches, rest, and frequent cough, he was finally feeling well. I had planned to go visit my elderly parents for the weekend. With the symptoms beginning, I decided to re-evaluate on Friday morning. I didn't want to take them any germs.

Day 2: Fri. May 15th. Woke up feeling "icky" and immediately postponed visiting my folks. A bad headache, cough, body aches and really sore throat came on gradually through the day until I was officially sick by late afternoon.

Day 3: Sat, May 16th. Full blown sickness all day. My sore throat was severe. The headache escalated with every cough and my over-the-counter meds didn't make a lot of progress against any of the symptoms. Lemonade, Popsicles, and fitful sleep punctuated by strange dreams were the theme of the day. I emailed my supervisor to let her know I needed a substitute for my nursing shift on Tuesday.  The way I felt, it was obvious I wouldn't be well enough to be around either patients or other staff by then. I assured her I'd be able to work my planned Friday shift, however.

Day 4: Sun, May 17th. The second day of "full blown sickness."  I was not feeling at all better this day.  I had no appetite at all, a very "icky" taste in my mouth, terrible sore throat, and a frequent cough with nasty green phlegm. My husband was again a huge help in bringing me fluids . . . I experienced constant muscle aches in the upper arms, thighs, abdomen, lower back, and what felt like spasms of deep bone pain to my left lower leg and right upper thigh. (I didn't have much headache from this day forth, however). By late evening I got out of bed and onto the couch to rest so hubby could sleep without being disturbed by my constant coughing, etc..

Late at night I felt well enough to putter around the kitchen briefly. But I suspected I was feverish and confirmed that with the thermometer. (Fever is nature's way of killing bad germs, so that doesn't frighten me at all by the way. I was hoping this meant the illness was going to peak and resolve). I began to experience chills and was generally just plain sick. I did take a dose of Tylenol (acetaminophen). My fever stayed in the 101-102.5 degree Farenheit range most of the night.

Day 5: Mon., May 18th. My highest temp was 103 degrees Farenheit at 6 am on Monday morning, but fever and chills stayed with me for several days. My cough was bringing up very thick, green phlegm. My plan this day was to call the hospital where I work to speak with the employee health nurse. I wanted her to know about my fever and influenza symptoms.  I also asked if our facility was doing any lab surveillance for flu among the employees. (We were not).

I also phoned my doctor's office to ask if they were interested in a sputum specimen for surveillance. (Again the answer was "no").  The nurse related my symptoms to the doctor, and advised that the doctor wanted to see me in the office based on my symptoms, but lab surveillance for H1N1 was only taking place in hospitalized patients in our community. There were no appointments available with my doctor on this day, and I honestly didn't feel well enough to get out of bed anyway so didn't even consider going to see her. I had my laptop at the bedside and felt well enough to write a blog note about my flu. I felt like a "wuss," because my health is robust, and I'm not used to being so fatigued and achy.

My only moments out of bed on this day were to visit the nearby bathroom. I caught a glimpse of my reflection and noticed my face was a waxy, pale yellow. I thought I looked jaundiced. My tongue was also, alarmingly, VERY PALE. I thought the fever had somehow left me anemic. For a moment I thought about checking the whites of my eyes in the mirror, but the room was too dark and the malaise made the hand mirror seem "too heavy." This was a day of feeling completely ill once again.

Day 6, Tues., May 19th. More of the same. I was again shocked to see how yellow my skin was as I passed the mirror. Once again, I thought about looking at my eyes with the hand mirror to check for icterus--but I simply lacked the energy. There was no noticeable improvement in body aches, sore throat, cough or fatigue. I stayed in bed, and was just up to soak in the tub briefly and use the bathroom. I had my laptop at bedside, but didn't have much interest in anything. Although I was technically "resting," it was difficult to get any satisfying sleep.

In the early evening, one of our cats was acting strange and hurt. It seemed like he'd been stung by a bee. We had no liquid benadryl for him in the house so I reluctantly dressed and went to the local Walgreens drugstore. I planned to grab a paper mask to wear in there, but they didn't have any. Not wanting to infect anyone, I made my purchase very quickly and immediately went home. Of course by then the cat seemed recovered enough not to need the medicine. I returned to bed immediately still feeling quite ill and coughing frequently with the constant sore throat and no appetite.

Day 7, Wed., May 20th. I had a feeling that I would not be able to work on Friday after all. I wasn't well yet--still coughing green stuff constantly. Still with a terrible sore throat. After no fever for two days, I started with chills again in the evening and a low grade temp of 100.5. I thought I'd better see the doctor the next day, just to get a note for work so they wouldn't think I was "playing possum."

Day 8, Thurs., May 21st. I was the patient in a mask at the doctor's office.  (Well, I did see one other patient in a mask). The doctor was surprised how sick I was.  She immediately acknowledged influenza and she also suspected possible pneumonia as a consequence.

New symptoms had also developed over the past 24 hours--my left eye was draining green pus. My temp was still hovering in the low 100's. My neck glands were swollen and tender. At the doctor's office I had a chest xray, throat culture and blood work. I told the doctor I felt 70% of normal--so much improved from earlier in the week. Still, the sore throat, cough, and malaise were lingering . . . I was prescribed antibiotic drops to instill in the infected eye.

I immediately returned home to rest. My husband kindly went to get the prescribed eye drops at the pharmacy, and while there he bought me a teddy bear. That's how pathetic I was--sick enough that my husband felt a teddy bear was in order . . .

Reluctantly, I had to notify my hospital yet again that due to this lingering illness I would have to cancel my next scheduled shift (on Sunday).

Day 9, Fri., May 22nd. My doctor called in the morning to give me some results. The chest xray hadn't been read yet by the radiologist, but the lab proved there was no bacterial infection in my throat. The unusual finding was in my blood work. My liver enzymes were alarmingly elevated suggesting that the influenza virus had battled with my liver and caused an acute hepatitis earlier in the week. My shocking yellow color on Monday and Tuesday was, indeed, jaundice.

I was actually feeling better this day . . . so much so that I decided to sanitize certain parts of the house. I focused on disinfecting my kitchen/dining area which included a thorough mopping of the floor and scrubbing of the sink, refrigerator, counters, and trash can. I vacuumed my living room including the crevices of the couch & chairs, did loads of laundry, changed all the sheets, and threw open the doors and windows to get fresh air in and germs out. I even cooked my son a light supper, but was totally spent from the activity before my husband made it home from work.

Overdoing it during that burst of energy really exhausted me. I took a 5-hour-nap on the couch before going to bed for a night's sleep.

Day 10, Sat., May 23rd. Because I had felt improved on Friday, I was optimistic that I'd be able to have a normal day. Instead I was once again very fatigued and my abdomen was very sore in the round ligaments from the constant deep productive cough. I mostly rested to make up from overdoing the house cleaning on Friday.

Day 11, Sun., May 24th. This was a day of actually feeling better for a change. As it was Memorial Day weekend, I wanted to take advantage of a sale at the nearby Bergners store. I drove over, purchased my items, and came home. The air was so fresh, I spent time in our yard, checking my flowers and vegetable plants. The herbs smelled so good, it was inspiring. I got out some branch cutters and did some pruning.

Once again, I later found that that trying to resume my usual level of activity was taxing enough to exhaust me into a long nap. When I woke up hours later, I was suffering from positional vertigo. I've had this vertigo (in which it feels as if the room is spinning when I turn my head) occasionally in the past, but it's always rather disconcerting.

Day 12, Mon., May 25th. The sore throat was almost gone. My eye was better. I still had positional vertigo. The cough was what I call "moist"; it was nagging in spasms that interfered with sleep, but not bringing up as much phlegm. My need for napping was ridiculously high, catching up on a sleep deficit from the illness, I am sure. I still had occasional body aches and pains related to the flu (including the deep "bone pain" in my right thigh that actually persisted on and off for months after this illness!) My appetite was not back and the "sickish-taste" was still there. But, I felt like I was 93% back to normal. Fortunately, I had no scheduled days of work this week.

Day 13, Tues., May 26th. My most lingering symptom was still the cough and a vague, generalized pain in my chest, a constant presence over the past week or so that was annoying but not unbearable. I still had positional vertigo, but my energy and enthusiasm started to return and I was feeling interested enough to write for a while. I planned to call my doctor to see what the xray result showed. I was keenly aware by this point as to what an unusually peristent illness this had become. Because the symptoms had waxed and waned so much, I wasn't even confident at this point that I was truly over it yet. (I am certain that I've never been affected by an illness for so long in my adult life).

Follow up: My chest xray was negative for pneumonia. A week after the first blood tests, my liver enzymes had returned to normal. I was still coughing "mildly" and bringing up (by then) clear phlegm into the first week of June when my son graduated from high school. By the second week of June, I was completely well, except:  my job requires a great deal of physical exertion and I must say that when I returned to work, I noted a distinct loss of stamina after my illness with the H1N1 Swine Flu.

My H1N1 Phlegm:  I took this phlegm photo at the end of my May 2009 bout with H1N1 Swine Flu.  I was feeling quite a bit better at the time, but still effortlessly coughing wads of disgusting phlegm.  I know it's gross . . . my lungs were full of this stuff, and it was much worse earlier in the illness before I had enough energy to document it.

Search terms that bring traffic to this blog post.  As of March 2010 my search log continues to show me that this is my most-read blog entry.  People most frequently use search terms that include "lingering cough," "yellow (or) green phlegm," "H1N1 with vertigo," and "H1N1 with jaundice (or) elevated liver enzymes."  (Importantly, I periodically also see search terms that suggest individuals have developed jaundice after receiving the vaccine against H1N1).

You might find these relevant articles of interest:

This page from the CDC website explains when it is recommended to collect specimens for H1N1 surveillance. Obviously we want to have an idea of how much influenza is out there, where it is located, and the emerging patterns of the illness. At the same time, it's unwise to test everyone, everywhere for the illness. We'd be expending resources at a cost that doesn't give us any benefit. Influenza as a general diagnosis can be made based on symptoms. Antibiotics are not a treatment for viral illnesses like influenza, and anti-viral medications are not frequently used either. This is one of those illnesses that requires our immune system to fight the virus.

Here is a 2006 article explaining a relationship between Influenza and a bout of acute hepatitis: Systemic Viral Infections and Collateral Damage in the Liver by David H. Adams and Stefan G. Hubscher. (American Journal of Pathology. 2006;168:1057-1059.) See paragraph 2, Understanding Hepatitis in Influenza.

Want to review the basics about influenza?  Here's a link to my general information about the flu.
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Fentanyl Transdermal Patches for Severe, Chronic Pain

A few days ago an elderly cancer patient was admitted to one of my rooms directly from the doctor's office for management of severe, chronic cancer-related pain. She rated her pain at "more than 10 of 10" on the pain scale. I'm always quick to give pain medication, but in this case we had no doctor's orders for one thing, and the supplies to access the patient's IV port-a-cath site (that's the same thing as an infus-a-port) hadn't arrived yet from the distant central supply department. Despite her pain, it was reassuring to review her home medication list and see that she had listed the Fentanyl transdermal pain patch among her medications. (Duragesic is a well-known brand-name for the Fentanyl patch.) The strong medication released from the patch on a slow, continuous basis is absorbed through the skin and provides great pain relief to most patients. Later in my admission assessment I asked her specific questions about the last time she took her home medications in order to complete the medication reconciliation process. It turned out that although the patient had filled the Fentanyl patch prescription, she had never used any of them.

My patient told me that after filling the Fentanyl patch prescription, she happened to catch an attorney's television commercial which warned about using Fentanyl patches. "The lawyer said those patches are 80 times more powerful than morphine, and they can kill a person." Unfortunately, my patient suffered quite a bit of intense pain and ended up admitted to the hospital due to that frightening television commercial. It's true that the Fentanyl is a MUCH stronger pain medication than morphine (about 100 times stronger), and certain circumstances related to this medication have come under well-deserved scrutiny in recent years--see FDA's 2007 Fentanyl Advisory--but with proper safeguards, this medication is both safe and very effective.

Some generic versions of the Fentanyl patch of the dosage 25 mcg/hr were recalled in 2008; check this list to learn more about the affected lots. The damaged patches released the pain medication too quickly, therefore putting patients at risk for an accidental overdose which could have caused them to breathe way too slowly--or not at all--due to oversedation.

I'll probably come back to tweak this blog entry later. For now, I want to point the reader to the patient information guide, instructions for use, and the "black box warning" for the Duragesic Fentanyl Patch.

The following "Important Safety Information" can be read in its entirety at the Duragesic site.

Here are some of the key points you need to know about using the (Fentanyl transdermal system) with my own bold/italics added to emphasize certain points.

• It is used to manage constant moderate to severe chronic pain that needs to be treated around the clock which cannot be treated by: combination narcotic, short-acting, or non-narcotic pain treatment products.
• It should only be used by people who are receiving or have developed a tolerance to pain therapy with products known as opioids. It should not be used if you have pain that will go away in a few days, such as pain from surgery, medical or dental procedures, or short-lasting conditions.
• One serious important side effect is slow, shallow, and/or difficulty in breathing, if the dose is too high. This sometimes happens the first time someone uses the product, so they should be watched more closely during the first 3 days of treatment.
• It can be abused in ways similar to other legal or illegal pain products. Care should be taken in storing this medication.
• It is a thin, adhesive, rectangular patch that is worn on your skin and delivers a strong pain-relieving medicine called Fentanyl through the skin and into the bloodstream. Using damaged patches can change the amount that is absorbed and cause too much medicine to be absorbed through the skin that can cause serious and sometimes fatal breathing problems.
• Do not combine with alcohol or other CNS depressants (e.g., sleep medications, tranquilizers) because dangerous additive effects may occur, resulting in serious injury or death.
• Avoid exposing the Fentanyl application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs, and heated water beds, while wearing the system. Avoid taking hot baths or sunbathing. There is a potential for temperature-dependent increases in Fentanyl released from the system resulting in possible overdose and death.
• Keep patches (new and used) out of the reach of children and others for whom Fentanyl was not prescribed. A considerable amount of active Fentanyl remains in the patch even after it has been used as directed. Accidental or deliberate application or ingestion by a child or adolescent will cause respiratory depression that could result in death.
• For more information about DURAGESIC® Fentanyl patches, talk to your doctor or call 1-800-526-7736, 9:00 AM - 5:00 PM (EST), Monday through Friday.

For additional information, here's a link to an FDA article, Proper Use of Fentanyl Pain Patches.

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