Viral haemorrhagic encephalitis due to influenza A virus (H1N1) – a case report

Dear Editor,
Viral encephalitis has a low incidence but high morbidity and mortality [1, 2]. On many occasions, it is difficult to diagnose due to the non-specificity of the condition, the number of possible differential diagnoses and the lack of resources that lead to a delay in its identification with the subsequent appearance of sequelae [3]. We pre­sent the case of a 48-year-old woman with a personal history of arterial hyper­tension (under home treatment with captopril 25 mg every 12 hours orally), dyslipidaemia (under treatment with atorvastatin 20 mg every 24 hours orally), type 1 diabetes mellitus (under treatment with a combination of metformin 50 mg and sitagliptin 1000 mg every 24 hours orally) and avascular necrosis of the femoral head (in treatment with a fentanyl patch 50 μg h^–1 subcutaneously), who attended the Emergency Department of our Hospital Centre due to abdominal pain in the right hypochondrium, nausea, vomiting and fever of up to 38.5ºC, of 48 hours of evolution. After analytical controls (low prothrombin activity (56%), high urea (51 mg dL^–1), altered liver profile (total bilirubin 5.5 mg dL^–1, direct bilirubin 5.1 mg dL^–1, AST 73U L^–1, ALT 72 U L^–1, gamma GT 91 U L^–1, LDH 406 U L^–1), metabolic acidosis (pH 7.20, bicarbonate 15 mmol L^–1 and base excess –12 mmol L^–1) and C-reactive protein 39.8 mg L^–1), the rest of the normal controls and abdominal ultrasound, she was diagnosed with acute cholecystitis and admitted to the General Surgery ward for conservative treatment with antibiotics. Twelve hours after her stay in the hospital ward, she presented haemodynamic instability with symptoms of hypotension and neurological deterioration. Urgent cranial computer-aided tomography (CT) was performed, which was normal, and as the patient was wearing a fentanyl patch for pain control, opioid levels were requested. Due to elevated fentanyl levels and presumed toxicity, intravenous naloxone was given to the patient. After the change in treatment, she presented agitation that was interpreted as a possible picture of opiate deprivation, worsening her level of consciousness to a score on the Glasgow scale of 9, with the appearance of a new fever peak of 38.5ºC. The laboratory assessment revealed: anaemia, thrombocytopaenia, and elevation of lactate dehydrogenase (LDH) and liver enzymes. For all these reasons, the...


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