Acute Influenza Encephalitis/Encephalopathy Associated with Influenza A in an Incompetent Adult

A 32-year-old male presented to the emergency department (ED) with a productive cough for 4 days and confusion for 2 days prior to presentation. He was febrile, tachycardic, and hypotensive. Initially, labs and influenza A/B PCR were performed. An elevated WBC of 17.3 and a lactate level of 3.1 were noted. He was given a bolus of normal saline and broad spectrum antibiotics, ceftriaxone and azithromycin. The patient was then subsequently found to be positive for influenza A via rapid antigen testing of the nares. On hospital day 2, the patient's mental status and respiratory distress worsened requiring intubation with mechanical ventilation. CT of the head without contrast revealed symmetric areas of hypoattenuation in the frontoparietal deep white matter. Lumbar puncture showed a slight elevation in WBCs and mild lymphocytic pleocytosis. Brain MRI without contrast revealed symmetric hyperintense T2 FLAIR signaling in the periventricular white matter and the splenium of the corpus callosum. He was found to have encephalitis secondary to influenza A and was started on a course of oseltamivir at higher doses of 150 mg BID for 2 weeks. On hospital day 10, after nine days of intubation, the patient received a tracheostomy due to failure to extubate and no improvement in mental status. He remained ventilator-dependent with little improvement in mental status; the patient was transferred to a long-term acute care hospital (LTACH) facility for further specialized care. He did not show any neurologic recovery or improvement in the three months after initial presentation of symptoms. In the fifth month after the initial symptoms, there was no recovery of preinsult neurologic function. The family had a palliative care meeting to discuss the plan and goals of care. It was decided by close family members that “compassionate extubation” would be done due to ongoing stress on the patient's body physically and neurologically. This case illustrates the importance of prompt identification and treatment of influenza in the prevention of rapidly progressive sequelae.