The victims of bird flu turn black

http://www.npr.org/templates/story/story.php?storyId=5315419

Then, just after the Battle of the Somme in the winter of 1916-1917, dozens of soldiers at the camp fell ill, complaining of aches, pains, cough and shortness of breath. Mortality was high at 40 percent, and some also had what later became known as a telltale sign of the killer flu: Their faces were tinged a peculiar lavender color, a condition known as heliotrope cyanosis.

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by: clark @ Mon Dec 11, 2006 at 02:38:41 AM CST

http://yaleglobal.yale.edu/display.article?id=6077

In December 1979, the British Medical Journal published a letter from an army physician that had laid undiscovered in a trunk in Detroit for 60 years. In the 1918 letter, the doctor who was attending to soldiers in Boston during the devastating pandemic that year described in graphic detail how they were dying from the flu: 'Two hours after admission they have the mahogany spots over the cheek bones and a few hours later you can begin to see the cyanosis extending from the ears and spreading all over the face, until it is hard to distinguish the colored man from the white.

'It is only a matter of a few hours then until death comes and it is simply a struggle for air until they suffocate.' (Cyanosis is a bluish or purplish tinge to the skin.)

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by: clark @ Mon Dec 11, 2006 at 02:42:02 AM CST

[ Parent ]

I think posting links

in the subject line is adversely affecting the Recent comments box???

Waiting for pogge or Dem to confirm ;-)

Cheers

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Mon Dec 11, 2006 at 02:45:32 AM CST

[ Parent ]

http://www.pbs.org/wnet/secrets/case_killerflu/

....in the 1918 flu, the rate was twenty-five times higher, with deaths usually the result of secondary bacterial pneumonia or bronchitis. Many flu victims in 1918 displayed a distinctive dusky blue-gray pallor on their face, lips, and ears, called heliotrope cyanosis -- a mark of a patient who is being suffocated to death by a buildup of fluid and cells in his lungs.

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by: clark @ Mon Dec 11, 2006 at 02:45:34 AM CST

[ Parent ]

mild-to-moderate thrombocytopenia

http://www.who.int/m...

In patients infected with the H5N1 virus, clinical deterioration is rapid. In Thailand, the time between onset of illness to the development of acute respiratory distress was around six days, with a range of four to 13 days. In severe cases in Turkey, clinicians have observed respiratory failure three to five days after symptom onset. Another common feature is multiorgan dysfunction. Common laboratory abnormalities, include leukopenia (mainly lymphopenia), , elevated aminotransferases, and with some instances of disseminated intravascular coagulation.

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by: clark @ Mon Dec 11, 2006 at 02:54:51 AM CST

Nine of the patients also had thrombocytopenia

Clinical and Treatment Considerations

A recent report of avian influenza A (H5N1) in 10 patients in Vietnam (see References: Hien 2004) demonstrated the following clinical features of the illness:

  * For eight of nine patients in whom a history of exposure to infected birds could be ascertained, the median time of exposure to onset of illness was 3 days (range, 2 to 4 days).
  * All patients presented with fever, shortness of breath, and cough; median time from onset of illness to hospitalisation was 5.9 days (range, 3 to 8 days).
  * Five patients (50%) reported sputum production and in three of these patients, the sputum was blood-tinged.
  * Seven patients (70%) reported diarrhoea.
  * None of the patients complained of sore throat, conjunctivitis, rash, or a runny nose.
  * All patients had abnormal chest radiographs at the time of admission (including extensive bilateral infiltration, lobar collapse, focal consolidation, and air bronchograms).
  * All of the patients had lymphopenia at the time of presentation; the median lymphocyte count was 700 per cubic millimetre (range, 250 to 1,100 with the lower limit of normal being 1500).
  * Nine of the patients also had thrombocytopenia; the median platelet count was 75,500 per cubic millimetre (range, 45,000 to 174,000 with the lower limit of normal being 150,000).
  * Eight patients (80%) died.
  * All patients received broad-spectrum antibiotics and five were treated with oseltamivir (four of whom died).

From (Hien 2004)

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by: clark @ Mon Dec 11, 2006 at 02:58:27 AM CST

Ebola Flu...

Calling this virus by a descriptive name that would elicit SOME attention was my suggestion months ago.  It seems the graphic details of the physiologic complications with this virus continue to be down-played. 

I assume this has occurred due to a few reasons...
1) Doesn't play well during prime time newscasts (mealtimes, kids, too much realism for REALITY shows, etc.). 
2) Due to patient privacy issues, videos won't be shown.
3) Last, but probably not least, is that it would scare the H*LL out of the public, and we currently have little to no solution to the problem.

Those of us that have watched a DIC patient (in extremis by definition), struggle for survival, cringe at the thought of a pandemic with DIC as the norm.  Additionally, the situation will be complicated by a deficit of resources, both human and material.  It defies rational thought.  Dealing with this would be one of the greatest challenges of my career.  And of my life. 

We seem to be in a lull for now.  I don't know if this is a real or a perceived lull, nor do I know it's duration.  But, it has helped push the vision of the nightmare I know is contained in your posts, to the background for now.  I know we do not have the resources to handle such an event.  No country does.  Mitigation may be our greatest accomplishment in such a situation. 

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by: nsthesia @ Mon Dec 11, 2006 at 10:12:07 AM CST

[ Parent ]

don't mix viral names

While this flu may cause DIC frequently, it has no relationship to ebola and confabulating those words would only cause confusion about that among the lay public.

Thrombocytopenia is a lowered level of platelets, a vital constituent to the formation of blood clots.  With lowered platelets, micro-bruises from ordinary activity that would usually be self-limited at the microscopic scale are able to grow into real bruises, while larger, not-unusual injuries can become serious bleeds (ie: i. v. needle site bleeding uncontrollably).

How do the platelets get lowered?

When there is tissue damage, the connective tissue scaffolding supporting the cells is exposed, triggering a response to repair the damage which includes clotting.  Also, when cells are damaged or die and rupture, proteins not normally found in the circulation are released into the blood stream from inside those cells.  In an ordinary situation these chemicals are limited to the area where damage has occurred, and so the clotting response is appropriately limited to the damaged area.

But when you have massive trauma or illness these exposed areas of scaffolding and damage are scattered around the body and so numerous that a circulating concentration of the 'clotting signal' buillds up in the blood.  The result is microscopic clotting at random points in the blood as it circulates.  These clots get caught in capillaries all over the body and cause microscopic 'strokes' of all different kinds of tissues, and depending on how much blood supply the area gets from alternate routes, can cause areas of oxygen deprivation and tissue death--more tissue damage to feed the fire.

This has two effects--you have these circulating clots, but making them has depleted all the resources used to make clots--so now when there's an injury, there's nothing to clot the spot and you bleed.  Plus the clots themselves are causing damage to the microvasculature by plugging it, which then causes damage which causes breaks in the microvasculature by which you can bleed.

In summary--

extensive cellular damage leads to
circulating pro-clotting factors leads to
microscopic clots in the circulating blood leads to
damage to the microvasculature leads to
holes in the microvasculature meanwhile
shortage of clotting factors because they were consumed by the circulating clots leads to
uncontrolled bleeding via the microvasculature holes leads to
bruising and 'strokes' in all tissues of the body  including the skin leads to
'mahogany spots' which age to become
dark bruises which make a person
look black.

The above process is called disseminated intravascular coagulation, or DIC.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 11:55:08 AM CST

[ Parent ]

DIC == "Blood Pudding Flu" ?

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by: a'Akova @ Wed Dec 13, 2006 at 00:23:23 AM CST

[ Parent ]

black flu?

I agree that the term currently in use "bird flu" has made it the subject of jokes in the general public. It is a silly name, misconstrues the danger (many people still think you only have to worry about not getting near chickens) and in general makes it very hard to convince people to take it seriously. I also agree with the concern that calling it Ebola flu would cause confusion and might backfire. However something like "Black Flu" has a good descriptive quality to it, and aligns it with the signs of black plague (and thus seriousness and urgency of the disease) without misconstruing it as plague. What's in a name? Everything. If we want to convince the general public of the danger we have to stop talking above their heads, as has been stated just recently on another thread, and use terms like fatality instead of mortality, death rate instead of CFR, etc. And call it the Black Flu instead of Bird Flu or avian influenza. Maybe we'll get somewhere.

Always have a plan B.

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by: maryinhawaii @ Tue Dec 12, 2006 at 10:09:48 AM CST

[ Parent ]

I agree, no mixing, I was just going for the "marketing effect"

by trying to get the public's attention.  For some reason, the word EBOLA strikes fear in the heart of the layperson.  Apparently, the descriptors of that viral infection hits home.  And while medical professionals can easily appreciate the differences between each viral entity, a moniker that is simple, yet descriptive, might help assist in educating the public, by first getting their attention.  But I agree, accuracy DOES count.

None-the-less, the terms avian influenza or pandemic flu, do not seem to make much of an impression.  And IMHO, the suggestion of Black Flu would not work today in our politically correct world.  (I may be wrong, but I believe many would find that offensive). 

Perhaps Hemorrhagic Flu? 

Or perhaps as suggested, just release a few descriptions of these patients in extremis, accompanied by a few post mortem photos.  Who knows?  My concern is that altho this virus has continued to evolve, and has been smoldering for so long without a full-blown H2H eruption, that people have become complacent and we're almost back to square one.  (Altho I AM glad to have extra time for planning and prepping, for those so inclined).

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by: nsthesia @ Tue Dec 12, 2006 at 12:45:40 PM CST

[ Parent ]

Bloody Flu

might get their attention.

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by: AVanarts @ Tue Dec 12, 2006 at 15:37:04 PM CST

[ Parent ]

Common laboratory abnormalities: leukopenia (mainly lymphopenia), mild-to-moderate thrombocytopenia

Clinical Signs and Symptoms in Humans5

According to the WHO, the highly pathogenic H5N1 virus has an aggressive course with rapid clinical deterioration and high fatality rates. Current data for H5N1 infection in humans suggests it may be longer than the seasonal influenza (2-3 days) with an incubation period anywhere from two to eight days or as long as 17 days.

Initial symptoms included below have been reported in some, not all, infected H5N1 patients. The spectrum of clinical symptoms may be broader than those mentioned.*

  * high fever, usually with a temperature higher than 38C and influenza-like symptoms
  * influenza-like symptoms
  * diarrhea, vomiting, abdominal pain, chest pain, and bleeding from the nose and gums
  * watery diarrhea without blood appears
  * respiratory symptoms
  * development of manifestations in the lower respiratory tract

Other clinical features 3 or more days post symptom onset:*

  * Difficulty breathing, respiratory distress, a hoarse voice, and a crackling sound when inhaling are commonly seen
  * Sputum production is variable and sometimes bloody
  * Blood-tinted respiratory secretions
  * Pneumonia (primary viral pneumonia)
  * Multi-organ dysfunction.
  * Common laboratory abnormalities: leukopenia (mainly lymphopenia), mild-to-moderate thrombocytopenia, elevated aminotransferases, and with some instances of disseminated intravascular coagulation.

These clinical features could change given the tendency of this virus to evolve quickly and unpredictably.

*Symptoms described were taken almost verbatim from resource cited to ensure accuracy due to the variability of symptoms in patients.

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by: clark @ Mon Dec 11, 2006 at 03:01:08 AM CST

hi clark good point

in fact, in the absence of other more sophisticated diagnostic tests in the middle of a raging pandemic, if one has access to a simple blood count, a low white count (especially lymphocytopenia) and even more so thrombocytopenia would be very important prognostic indicators of severe disease. 

I can imagine using that plus respiratory rate as deciding factor to try more heroic treatments in the absence of X-ray or other facilities. 


All 'safety concerns' are hypothetical.  If not, they'd be called side effects...

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by: SusanC @ Mon Dec 11, 2006 at 05:36:14 AM CST

[ Parent ]

the last comment is from the United States Department of Agriculture

http://fsrio.nal.usd...

Forgive me for putting links in the Subject line.

Also forgive me for bombarding the wiki- I am just trying to make a point- and ask a huge question. Why are we hiding this?????

It is like that bullshit thing they tell you when you are a kid. We are going our old Poodle Dog "to sleep". No, we are going to KILL him. Tell the truth! JMHO

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by: clark @ Mon Dec 11, 2006 at 03:05:55 AM CST

Proof in the Seeing

Clark, you are right. I believe most people think, "So, if I get bird flu, I'll just have to spend a week or two in bed. Big deal." One picture is worth a thousand words; if there was excellent media coverage of what bird flu actually looks like in a person, you bet people would sit up and take notice. It would be terrifying. Then mention the current CFR while you've got their attention and all of a sudden, I bet they "get it."

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by: Northstar @ Mon Dec 11, 2006 at 08:07:30 AM CST

[ Parent ]

Who would want to print a picture? Nature mag.?

Time?  Not a medical journal, because they know what cyanosis is.  It's ready made for a paranoia publication ("Look what they're hiding from you!") but that won't be respectable.  Maybe on a website that news articles can link to?  There are always protesting letters from parents whose kids have seen newsphotos of bodies in Newsweek, etc.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

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by: Jane @ Mon Dec 11, 2006 at 10:30:51 AM CST

[ Parent ]

Seeing is Believing

I was thinking more of live TV news segments. I've seen the Indonesian news clips of little children using respiratory support being loaded into ambulances with the EMT's in full biohazard gear... believe me it made an impression. But as far as print, National Geographic to its credit doesn't seem to shy away from documenting some of the uglier aspects of a story. Their photo of the funeral of a child killed in the Beslen massacre is graven on my mind, still, with an immediacy no other approach to that story could have managed.

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by: Northstar @ Mon Dec 11, 2006 at 10:58:17 AM CST

[ Parent ]

cyanosis, slightly o/t

I ran across a great (but horrifying) site a while back about the Chernobyl disaster. In one place there was a story about one of the firefighters who was sent in to fight the fire the night of the disaster. They were given virtually NO protective gear, and nothing that was any way adequate for the situation.

This firefighter lost consciousness at the scene and woke up in a hospital ward with a bunch of his fellows. They were joking about the radiation, etc. Later one of them started bleeding from his nose and mouth, turned black, and died.

The way it was described conveyed the absolute horror of the firefighter at seeing this. Probably why they aren't talking about it. It's just too horrible.

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by: gardner @ Mon Dec 11, 2006 at 10:44:28 AM CST

on people turning black

If news reports started saying with horror: The victims turn black! I would imagine this might be annoying (or worse) to people who ARE black. And this would cause all sorts of problems. And "turning black" might depend on how much pigment you have. What do sub-Saharan Africans, et al., look like with cyanosis?

It would also cause problems for rivals of the All-Blacks.

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by: gardner @ Mon Dec 11, 2006 at 11:13:17 AM CST

Re: on people turning black

I think you've hit the nail on the head, so to speak. After the first round of "Victims turn black" headlines, and the followup complaints, you'd probably see something a little more PC: "Victim's skin slightly discolored by virus"

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by: Bronco Bill @ Mon Dec 11, 2006 at 11:36:22 AM CST

[ Parent ]

Re: on people turning black

It isn't just about being PC (a term I hate), it's also about being accurate.

Do black people turn black? I remember this problem with some other condition (skin cancer?? -- can't remember). They described the symptoms as they appeared in people with fairly light skin (whites, some asians, etc). But in the widely distributed standard information, people with dark skin were given no information on what their symptoms would look like. In order to fight this properly, we need accurate information.

"Skin discolored by the virus" might be more accurate (just teasing you here), followed by "caucasian skin can appear X; brown skin can appear Y, dark brown skin can appear Z"

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by: gardner @ Mon Dec 11, 2006 at 11:50:01 AM CST

[ Parent ]

"dusky purple" would be a better descriptor. n/t

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 11:56:41 AM CST

[ Parent ]

for different skin colors

do you know how it would differ (if at all) for different skin colors?

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by: gardner @ Mon Dec 11, 2006 at 11:59:22 AM CST

[ Parent ]

harder to see on dark skin...

The phenomenon is harder to see on darker skin.  It generally begins as spots and then these consolidate; while spotty you can see it because you see irregularity in skin tone.

There's enough variability in human skin tone among dark skinned people that you have to sort of calibrate your eyes to each individual case before the manifestations become overwhelming.  Since most cases are like the second set of pics I linked to, usually there's enough spared skin to have some normal areas for comparison.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 12:24:29 PM CST

[ Parent ]

RE: sub-Saharan Africans with cyanosis

What do sub-Saharan Africans, et al., look like with cyanosis?

Your question may have been rhetorical but, on the chance that it wasn't -- the answer is that one examines the conjunctiva (inner surface of eyelids) and nail beds of sub-Saharan Africans, and evaluates the color changes there. The patients I observed in Kenya 30 years ago were so dark-skinned that the standard North American or European concept of circumoral (around the mouth) cyanosis would have been meaningless.

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by: Dennis in Colorado @ Mon Dec 11, 2006 at 12:00:26 PM CST

[ Parent ]

wasn't rhetorical. thanks. n/t

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by: gardner @ Mon Dec 11, 2006 at 12:02:35 PM CST

[ Parent ]

Purple fingernails

This is correct Dennis. The way to tell if an African American is becoming cyanotic is to check their nail beds.  They will darken and turn a disky blue when their blood oxygen level is low.  Their skin darkens also but unless you know the person before hand, you might not recognize this change. 

Grattan Woodson, MD

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by: The Doctor @ Wed Dec 13, 2006 at 14:22:06 PM CST

[ Parent ]

Doh! (see what you forget when you're not in clinic?) n/t

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Thu Dec 14, 2006 at 14:13:55 PM CST

[ Parent ]

a picture of the phenomenon

Here is a picture of what is going on with a fairly severe case of disseminated intravascular coagulation.

In this image (the hand of a patient with severe DIC), you see the purple/black bruising around the base of the thumb, and you also see the true-black dry gangrene of the finger-tips as the level of clotting in that area exceeded the available circulation. 

Left to its own, if the patient recovers, these dead fingertips will eventually fall off on their own, and in most cases ordinary hygiene can keep the area clean enough that the wounds will heal well.  This generally results in more preservation of viable tissue than any attempt to surgically remove the dead tissue.

http://inet.uni2.dk/...

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 12:13:17 PM CST

a less severe/more typical case of DIC

Here's a link to what you more commonly see with this problem:

http://www.coldbacon...

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 12:16:30 PM CST

[ Parent ]

Blech n/t

Our children change our lives, whether they live or not.
www.misschildren.org

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by: Carrey in VA @ Mon Dec 11, 2006 at 12:19:12 PM CST

[ Parent ]

Thanks for those pics - I thought

it would like the "bruising" you get in the elderly when the skin and vessels burst at the slightest touch - well that is how it seems.  Because of the profuse bleeding under the skin, it holds that blood black look without the usual purple and yellowing seen with bruising in younger people.

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Mon Dec 11, 2006 at 12:54:30 PM CST

[ Parent ]

I think it is technically a 'vasculitis' rather than 'bruising'

but it looks like bruises.  When people start to recover it gets that yellowing appearance as the hemoglobin is recycled and only traces of it remain.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Mon Dec 11, 2006 at 13:17:38 PM CST

[ Parent ]

an artists impression

I google image searched cyanosis and thrombocytemia. There isn't much. There is what looks like an artists impression here.

http://www.pbs.org/w...

I also believe that there is a difference in skin color of a living victim, immediately before death and the colour of their corpse sometime later. I am guessing that the very sick, but still alive person is purplish. After their death, their skin is more blue/black.

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by: clark @ Mon Dec 11, 2006 at 14:18:32 PM CST

"Black November, the 1918 influenza pandemic in New Zealand"

"Black November, the 1918 influenza pandemic in New Zealand",
by Dr. Geoffrey Rice, Associate Prof of History at Cantrerbury University.
pub by Canterbury University Press, 2005. p 7

This book has its origins in an afterdinner conversation with my father in 1977.... I asked him to name the most vivid experience of his childhood. Without a moments hesitation he replied, "Why the Black Flu, of course". This rang no bells for me, so I asked, "When was that"? His reply, as I recall, went something like this;

"That was the big flu epidemic at the end of the First World War. I thought everyone had heard about the Black Flu. You wouldn't forget it if you'd lived through it. People collapsed and died like flies, even big strong men in the prime of life. In fact it would affect them worse than the weedy types.... It went through the country like wildfire. Thousands died in that flu, especially the Maoris. They seemed to get it worse than the rest of us. But I don't remember ever seeing an official death toll. Perhaps they were too afraid to publish the figures."

He told me how Taumarunui (a railroad town in the middle of the North Island of NZ) had come to a complete standstill for what seemed several weeks, with all the shops and pubs shut and nearly every adult in the town laid low with the flu. His family was one of the lucky ones that seemed to be immune. my grandparents spent all day, every day, visiting their sick neighbors and feeding the convalescents. At first my father went with them. His job was to light the fires each morning in the coal ranges which then heated the water and warmed the houses. He was very proud of his system. Having set the paper and kindling in three houses, he would return to light them, and by the time the third one was lit, the first one would be ready for more wood. He then would repeat the round to add coal, before moving on the the next three houses. Nobody needed to lock their doors at night in those days.

As well as lighting the fires, my father also had to look into the bedrooms to see if anyone had died in the night. In my ignorance I asked, "How could you tell? They'd just look as if they were asleep". I will never forget the shock of his reply;

Öh, you could tell all right. In that flu, when they died, the bodies turned black. That is why our Nanna always called it the Black Flu. In one house I looked into a bedroom and there was the wife, still fast asleep, and her husband dead and black beside her. It was a terrible time. I had to turn it in (quit) after that, I just couldn't carry on."

He was only nine years old in 1918. 

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by: clark @ Mon Dec 11, 2006 at 14:23:10 PM CST

There is a Diary dedicated

to this book - you can find it here

http://www.newfluwik...

Several extracts, thanks to clark and others, from the book, giving some amazing insights.

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Mon Dec 11, 2006 at 18:37:07 PM CST

[ Parent ]

forgive the scary, morbid images

I know that decision makers read these wiki pages- and also lots of Moms and Dads and Grands and GreatGrands and brothers and and sisters. I am in the later group and not in the first.

I agree with Northstar when she says the common belief is- "So, if I get bird flu, I'll just have to spend a week or two in bed. Big deal."

People need to grok that this is not "the flu" as we have all experienced it. It is the potential difference between a "big wave" and a "tsunami".

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by: clark @ Mon Dec 11, 2006 at 14:35:30 PM CST

I meant " Ï am in the former group and not in the later"

correction

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by: clark @ Mon Dec 11, 2006 at 14:36:57 PM CST

[ Parent ]

I just shake my head.

clark, I think this is exacerbated in the U.S. by what scant flu publications there are mentioning that people "might" have to stay home "up to 2 weeks" to avoid infecting others. Like they are going to be popping up and at it, back to work, in two weeks!

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by: Northstar @ Mon Dec 11, 2006 at 15:57:30 PM CST

[ Parent ]

Hi Northstar

I have this weird thought that I rarely voice. Maybe we are just stupid Human-Turkeys getting raised-up/fattened-up for a Flu Virus Wedding celebration? How can we be so blaise? We know all of this information- but no one wants to voice it. Are we afraid of pissing off Farmer Flu?

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by: clark @ Mon Dec 11, 2006 at 16:54:14 PM CST

[ Parent ]

{{Waving}}

...from this side of the globe. (s) Not so weird an idea -- I think sometimes we humans think we possess some elevated status in the natural order. A pandemic can't happen to us because, well, it just can't happen to us. We're special. We're smart!

Well, no, we're meat. Walking, talking, thinking meat, but meat nonetheless. And as long as there's been meat, there's been other things that have wanted to eat it, from large to small.

I think the single most depressing thing I've read recently has been the about the thousands of lowland gorillas that have been killed by Ebola... 95%CFR, they figure. Just more meat, and are us smart primates so different to the viral eye?

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by: Northstar @ Mon Dec 11, 2006 at 18:40:42 PM CST

[ Parent ]

the active side of infinity

Hi Northstar
Carlos Castaneda's swansong was a book called "The Active Side of Infinity" which I am almost certain you will love reading. Especially read the chapter towards the end of the book called "Mud Shadows"- if you get a chance to.

I am glad that you are out there- I appreciate your presence!

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by: clark @ Mon Dec 11, 2006 at 21:41:13 PM CST

[ Parent ]

Journy to Ixtilasomething (g)

Oh, I loved Castenada's series, what was it... "A Separate Reality" or something like that. I could never quite figure out if it was fiction or his actual experiences! I'll have to look for "The Active Side of Infinity" to take me on another head trip now that I've let the girls off school. (G) Glad you're there to talk to, too... you're one of the few on my "subscribe" list so I don't miss a post. (s)

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by: Northstar @ Wed Dec 13, 2006 at 19:04:35 PM CST

[ Parent ]

Heliotrope cyanosis

There is a colored artist rendering of a WW I British soldier with heliotrope cyanosis here:

http://www.pbs.org/w...

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by: bgw in MT @ Mon Dec 11, 2006 at 15:31:39 PM CST

Oops! Sorry, that's the same pic Clark posted. n/t

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by: bgw in MT @ Mon Dec 11, 2006 at 15:38:46 PM CST

[ Parent ]

Petechiae and purpura

http://health.allref...

The link is to photos of "Purpura"

Thrombocytopenia: Bruising, Bleeding, Clotting failure, Petechiae (reddish purple spots) Bleeding into skin, Purpura, Oral bleeding, Nosebleeds, Vaginal bleeding, Gastrointestinal bleeding, Blood in stool, Black stools Blood in urine, Enlarged spleen.

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by: clark @ Mon Dec 11, 2006 at 16:45:30 PM CST

Thanks for addressing this...

I have been wondering about it since, as you said, there is little/no mention of cyanosis with H5N1.  My recollection from 1918 first hand accounts was that once the blue appreared appeared it meant death was imminent.

Another thing I've noticed is that H5N1 seems to be slower in killing its victims than H5N1. While medical intervention may be delaying the inevitable, I don't recall any H5N1 reports stating "he was fine in the morning and by night he was dead" like you did with 1918 H1N1.  Most victims go to hospital at 3-5 days when they take a turn and it clearly isn't seasonal flu.  But even with aid they die in 7-10 days.  If that's the case, is it a blessing or a curse?  More time to try and beat it, or more time to torment the victim and his/her family in the false hope of a miracle? 

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by: LauraB @ Mon Dec 11, 2006 at 18:34:30 PM CST

Ventilators

Another thing we see routinely in the cases in Indonesia is that putting people on ventilators is often not helpful.  Anecdotally, it seems that if an individual goes on a vent, they rarely come off in an improved condition later.  Sometimes they do, but rarely.  I've realized that once someone goes on a ventilator, it has become nearly equivalent in my mind to their not surviving, much like the "turning blue" did in 1918. 

No one is talking about this issue either, and it is an important one.  In the first world, people will expect ventilators to be used, regardless.  But, there will not be enough of them.  Also, ventilators are resource expensive.  We need to objectively evaluate whether they work well enough to justify increased investment in and reliance on them (an investment made mentally, as well as practically). 

We can't do that, though, if we don't talk about that data.  We don't even have an organized summary of that data to evaluate (and I mean an official one, as in from WHO). 

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by: Pixie @ Tue Dec 12, 2006 at 08:07:31 AM CST

[ Parent ]

Ventilators are merely the means to an end.

IMO, only those patients "lucky enough" to get ill early in the course of a panflu will get access to them anyway.  The rest will get access if luck shines their way by accident. 

The cost of purchasing additional vents is so prohibitive, that I do not see institutions increasing their inventory in anticipation of a panflu.  They will be considered a luxury item.

As for their usefullness, once a patient presents with ARDS, it is an uphill battle to achieve any positive outcome.  And that is with all current resources available, which I do not expect to have in a panflu.  I've seen patients linger for weeks on a vent with ARDS, only to expire.  Will we have the luxury of that much time to allow patients to prove their viability?  I doubt it. 

I believe we already have a pretty good idea of who is a good candidate (clinically) for mechanical ventilation.  What is lacking are the policies to deal with the ethical considerations of denying or removing said equipment from live patients. 

IMO, having these discussions and educating personnel on such matters is critical. 

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by: nsthesia @ Tue Dec 12, 2006 at 12:14:22 PM CST

[ Parent ]

Black Flu

Rename it Black Flu instead of bird flu. That might get
the attention of the general public and put this disease in proper perspective.

Always have a plan B.

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by: maryinhawaii @ Tue Dec 12, 2006 at 10:12:56 AM CST

Blue flu- because you turn blue from lack of oxygen after your lungs swell

and stop working.  Someone said it's like trying to breathe through steak.  Too long to be catchy, though.  Oh, blue flu is a police work slowdown, isn't it? 

Panflu, and you turn blue.  It rhymes, anyway.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

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by: Jane @ Tue Dec 12, 2006 at 13:05:17 PM CST

[ Parent ]

Black Flu

In "Black November" by Geof Rice, time and time again, the 1918 flu in New Zealand is referred to as "The Black Flu" by the people who were recounting their experiences of the time. Was the 1918 flu called the Black Flu in the US, Canada, Europe, India- the rest of the world? Does anybody know? "The Spanish Flu" sounds like a name invented by the authorities. What were ordinary people calling it? I suspect it was called "The Black Flu" or the equivalent in their language- by everybody, everywhere.

But of course, almost nothing is written about 1918 flu- which I cannot even begin to understand.

1918 flu killed something like four times more people than the 
the Black Plague.

AIDS has killed 20,000,000 in 20 years.
The flu in 1918 killed 2 to 5 times that number people in a few months.

It is humanities biggest "within living memory", secret.

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by: clark @ Tue Dec 12, 2006 at 14:03:25 PM CST

[ Parent ]

I've always heard it called the Spanish Flu.

Or, the "Spanish Lady." 

I've also read that in Spain, they called it the "French Flu."

It is my understanding that Spanish doctors were the first to identify it as a new illness.

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by: AVanarts @ Tue Dec 12, 2006 at 15:28:48 PM CST

[ Parent ]

It was called Spanish Flu

because the Spanish were the only ones without censorship over their newspapers at that time and they were reporting cases and casualties.  No other country was talking about it.

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Tue Dec 12, 2006 at 19:54:47 PM CST

[ Parent ]

More flu names

I like "The Black Flu" but "The Killer Flu" has simplicity in its favor. I think wewe'll see what actually catches on in the popular vernacular if it breaks out in a big way. (I always like to use "IF".)

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by: Northstar @ Wed Dec 13, 2006 at 19:08:09 PM CST

[ Parent ]

A Flu by any other name....

Call it Violet Flu (violet for purple, and you can pronounce it with a southern (USA) accent and it will sound like you are saying 'violent' which will kill two birds with one stone... pun intended).

This flu by any other name will still be as deadly...

PANIC/09 (Porcine Avian Novel Influenza Contagion / 2009)

A prudent man sees danger and takes refuge,
  but the simple keep going and suffer for it.
Proverbs 22:3

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by: David @ Tue Dec 12, 2006 at 11:55:29 AM CST

Flu names

I've heard it referred to as "the grippe," but I don't think that's a harsh enough term to get serious attention.

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by: Meserole in FL @ Tue Dec 12, 2006 at 17:53:44 PM CST

the grippe

When I first started reading the flu wiki and saw the term "the grippe" it brought back the memories of my grandma telling me as I would put on my coat that I needed something on my head or I would get the grippe, and she would reach towards me with her hand as if she were about to choke me when she uttered those words. It might not be harsh enough for most people, but it still sends chills down my spine when I hear that term as I picture a boney hand reaching towards my throat wanting to choke the life out of me.

PANIC/09 (Porcine Avian Novel Influenza Contagion / 2009)

A prudent man sees danger and takes refuge,
  but the simple keep going and suffer for it.
Proverbs 22:3

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by: David @ Wed Dec 13, 2006 at 07:31:56 AM CST

[ Parent ]

"the grippe" because the victim couldn't breathe, as if being choked?

I'd forgotten that term (I never had your image of a hand reaching for me, though.)  I think it was an illness more serious than a cold, but probably not a stomach ailment.  It's hazy now.  In 2006, the terror of our grandparents "grippe" is gone, though, so "grippe" won't resonate without some publicity work.

"The truth does not change according to our ability to stomach it."  Flannery O'Connor

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by: Jane @ Wed Dec 13, 2006 at 11:43:43 AM CST

[ Parent ]

La grippe...

= influenza en francais...

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by: nsthesia @ Wed Dec 13, 2006 at 11:02:34 AM CST

[ Parent ]

we've been talking about Spanish flu here

but I don't actually recall anything about H5N1 victims turning black.

There's been mention of gingival bleeding, which is a hemorrhagic symptom, and there's been prominent ARDS in these patients, but I don't think that hemorrhagic symptoms have been all that prominent.

La grippe is, as nsthesia said, simply 'the flu' in French.

Black flu may have been a colloquial term for the Spanish flu (called Spanish flu because at the time only the Spanish press was not being censored and admitted it was a problem).

Hemorrhagic flu would describe H1N1 1918 but not H5N1 2007.

"ebola flu" would be frankly misleading, particularly since hemorrhagic symptoms are not that prominent in H5N1, and of course because the viruses are completely unrelated.

You may want a catchy scary name now to get people's attention, but I can pretty much guarantee that TPTB will want one to downplay the problem.  In a head-on collision between their agenda and yours, guess who wins?

This flu is killing people by causing ARDS.  But ARDS isn't well known to people on the street, so doesn't form a basis for a catchy name.

Heliotrope cyanosis--cyanosis means blue coloration, generally from lack of oxygen.  Heliotrope means in the places where the sun shines--so imagine a light on someone's face, the areas in the light would be those with the most prominence of the cyanosis.

Some readers here seem to understand what they're reading.  Others may want to invest in a good medical dictionary.  I see people getting hung up a lot on vocabulary.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Wed Dec 13, 2006 at 12:31:45 PM CST

Here is where it says that H5N1 victims are turning black (thrombocytemia)

Wong SS, Yuen KY. Avian influenza virus infections in humans. Chest, 2006 Jan;129(1):156-68.

"turning black" is indeed a colloquialism. But as I said earlier on in the thread, the victims of H5N1 are turning bue/purple towards the later part of their illness. After death, I would assume that large parts of their bodies would be blue/black. This is what happened in 1918. Nobody has described the state of the dead bodies of H5N1 victims- but the information is out there. Somebody write in.

They had "cyanosis" or "heliotrope cyanosis" or displayed "thrombocytemia" or "purpura" or "DIC (disseminated intravascular coagulation)" or "Petechiae". Yes, in other words, they turned black.

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by: clark @ Wed Dec 13, 2006 at 13:22:13 PM CST

[ Parent ]

you're confusing words here

Thrombocythemia is an *excess* of platelets that does not occur in influenza.

Thrombocytopenia is a *shortage* of platelets that does occur in influenza.

Thrombocytopenia is not the same as turning black.  It is a description of a laboratory measurement from a blood sample.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Wed Dec 13, 2006 at 21:33:58 PM CST

[ Parent ]

"The most striking laboratory findings were marked lymphopenia and thrombocytopenia"

NEJM -- Avian Influenza A (H5N1) in 10 Patients in Vietnam

Tran Tinh Hien, M.D., Nguyen Thanh Liem, M.D., Nguyen Thi Dung, M.D., ... In January 2004, there was confirmation that influenza A (H5N1) virus had been ...

http://content.nejm....

"The most striking laboratory findings were marked lymphopenia and thrombocytopenia"

In other words, 9 out of 10 of the patients changed skin colour (turned black).

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by: clark @ Wed Dec 13, 2006 at 15:50:03 PM CST

[ Parent ]

a definition of Idiopathic Thrombocytopenic Purpura

Idiopathic Thrombocytopenic Purpura

Definition

Idiopathic thrombocytopenic purpura, or ITP, is a bleeding disorder caused by an abnormally low level of platelets in the patient's blood. Platelets are small plate-shaped bodies in the blood that combine to form a plug when a blood vessel is injured. The platelet plug then binds certain proteins in the blood to form a clot that stops bleeding. ITP's name describes its cause and two symptoms. Idiopathic means that the disorder has no apparent cause. ITP is now often called immune thrombocytopenic purpura rather than idiopathic because of recent findings that ITP patients have autoimmune antibodies in their blood. Thrombocytopenia is another word for a decreased number of blood platelets. Purpura refers to a purplish or reddish-brown skin rash caused by the leakage of blood from broken capillaries into the skin. Other names for ITP include purpura hemorrhagica and essential thrombocytopenia.

Description

ITP may be either acute or chronic. The acute form is most common in children between the ages of two and six years; the chronic form is most common in adult females between 20 and 40. Between 10% and 20% of children with ITP have the chronic form. ITP does not appear to be related to race, lifestyle, climate, or environmental factors.

ITP is a disorder that affects the overall number of blood platelets rather than their function. The normal platelet level in adults is between 150,000 and 450,000/mm3. Platelet counts below 50,000 mm3 increase the risk of dangerous bleeding from trauma; counts below 20,000/mm3 increase the risk of spontaneous bleeding.

Causes and Symptoms

In adults, ITP is considered an autoimmune disorder, which means that the body produces antibodies that damage some of its own products—in this case, blood platelets. Some adults with chronic ITP also have other immune system disorders, such as systemic lupus erythematosus (SLE). In children, ITP is usually triggered by a virus infection, most often rubella, chickenpox, measles, cytomegalovirus, or Epstein-Barr virus. It usually begins about two or three weeks after the infection.
Acute ITP

Acute ITP is characterized by bleeding into the skin or from the nose, mouth, digestive tract, or urinary tract. The onset is usually sudden. Bleeding into the skin takes the form of purpura or petechiae. Purpura is a purplish or reddish-brown rash or discoloration of the skin; petechiae are small round pinpoint hemorrhages. Both are caused by the leakage of blood from tiny capillaries under the skin surface. In addition to purpura and petechiae, the patient may notice that he or she bruises more easily than usual. In extreme cases, patients with ITP may bleed into the lungs, brain, or other vital organs.

http://www.answers.c...

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by: clark @ Wed Dec 13, 2006 at 16:22:19 PM CST

[ Parent ]

ITP and DIC

Idiopathic/immune thrombocytopenic purpura does not occur in flu. (ITP)

Disseminated Intravascular Coagulation can occur in severe illness or injury from any cause. (DIC)

Though the syndromes are similar they are not the same thing.  I suggest you google each one and read the differences.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Wed Dec 13, 2006 at 21:37:08 PM CST

[ Parent ]

ITP often occurs after flu-like illnesses

http://www.mayoclini...

Mayo Clin Proc. 2004;79:504-522 © 2004

Management of Immune Thrombocytopenic Purpura in Adults
ROBERTO STASI, MD; DREW PROVAN, MD

In children, ITP is usually an acute, self-limiting disease, often occurring 2 to 3 weeks after a viral infection (varicella, rubella, mumps, upper respiratory tract infection, gastroenteritis, flu-like illnesses, etc) or immunization.

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by: clark @ Thu Dec 14, 2006 at 00:03:37 AM CST

[ Parent ]

ITP often occurs after flu-like illnesses

http://www.mayoclini...

Mayo Clin Proc. 2004;79:504-522 © 2004

Management of Immune Thrombocytopenic Purpura in Adults
ROBERTO STASI, MD; DREW PROVAN, MD

In children, ITP is usually an acute, self-limiting disease, often occurring 2 to 3 weeks after a viral infection (varicella, rubella, mumps, upper respiratory tract infection, gastroenteritis, flu-like illnesses, etc) or immunization.

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by: clark @ Thu Dec 14, 2006 at 00:06:25 AM CST

[ Parent ]

Relapse of idiopathic thrombocytopenic purpura caused by influenza A virus infection

Relapse of idiopathic thrombocytopenic purpura caused by influenza A virus infection: a case report

Hiroto Kaneko

Journal of Infection and Chemotherapy
  Volume 10, Number 6 / December, 2004

Abstract  We report a patient with idiopathic thrombocytopenic purpura (ITP) in remission, who relapsed as a result of an influenza A virus infection.

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by: clark @ Thu Dec 14, 2006 at 00:22:29 AM CST

[ Parent ]

clark

Those are post-viral autoimmune syndromes, more related to things like myasthenia gravis triggered by flu than to thrombocytopenia during the acute phase of the viral illness, which is more likely due to platelets being consumed by trying to clot over damaged tissue, or to DIC when clotting factors become so numerous as to circulate freely in the circulation rather than locally near an injury.

Anyone can use google scholar to look up keywords.  You have to put some effort into understanding what you read.  Something that happens weeks after the virus is cleared as a result of peaking antibody counts is not the same as something that happens early in illness when the virus is actively replicating and antibodies have not yet had time to reach appreciable levels.

Low thrombocytes are an indicator that something is wrong, but they are not an indicator as to *what* is wrong.  Just like fever is a non-specific symptoms that can indicate a variety of causal problems but is not specific to any particular problem.

You are obsessing about a lab value whose primary use in this situation (but not in other situations) appears to be predicting who will more likely progress to ARDS.  If you consider that the platelets are consumed by tissue damage and that is why platelet count drops, it makes sense that if the lungs were becoming more damaged the platelets would drop in concert with that, as they clot out as part of the body trying to repair itself.  The more repair is attempted, the lower the supply of platelets gets, as long as consumption of platelets exceeds the production rate.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Thu Dec 14, 2006 at 00:46:08 AM CST

[ Parent ]

using references

Lisa, could you please reference your statements. I have.

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by: clark @ Thu Dec 14, 2006 at 02:08:40 AM CST

[ Parent ]

how do you 'reference' 4 years of MD training + clinical training?

You could try hacking through Harrison's Textbook of Medicine on the topics of Disseminated Intravascular Coagulation and on Idiopathic Thrombocyopenic Purpura.  I suggest you borrow it at the library or read it in a hospital-library or bookstore, as it costs over $100 to buy and is rather dense with jargon for a non-medical reader.

A dedicated lay reader with a good medical dictionary at hand could hack through a few targeted sections, but reading too much of it would prove exhausting for someone without the basic medical science background.

You could also try chapter 37, "Platelets in Critical Illness", The ICU Book 3rd ed., Paul L Marino, Lippincott Williams and Wilkins, 2007 (this new edition of  this 'standard' book on ICU care is *just* released; I got it on pre-sale special at a continuing medical education conference).  ISBN-13: 978-0-7817-4802-5


medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Thu Dec 14, 2006 at 14:05:49 PM CST

[ Parent ]

GP means General Practicioner or Georia Pacific or Grand Poobah

Lisa, putting "GP" after a pet name, doesn't give you any special status. It looks silly to me. I guess you went to college? Which one? Where was it? What were your grades? Did you do any Post Doc research? What was your thesis? Are you published? What journals? Anything at all to do with blood chemistry?

You are implying that you are a general practicioner. Good for you. That is a real accomplishment.

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by: clark @ Thu Dec 14, 2006 at 16:18:50 PM CST

[ Parent ]

clark

What is your problem, anyway?

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Thu Dec 14, 2006 at 16:52:36 PM CST

[ Parent ]

clark, drop it

Apparently, boorish behavior is not limited to Americans.

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by: DemFromCT @ Thu Dec 14, 2006 at 17:01:07 PM CST

[ Parent ]

Forgive me for being so insensitive to your remarkable American Culture

Forgive me. If we just stay with cooky recipes and tips on bulk buys at Costco, I won't offend. Forgive me for being so insensitive to your extraordinary American Culture. I am just an ignorant foreigner.

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by: clark @ Thu Dec 14, 2006 at 17:46:30 PM CST

[ Parent ]

lymphopenia

"Lymphopenia and thrombocytopenia were common findings in all series; these were prognostic indicators for ARDS and death."

These held the same prognosis for victims in Vietman of H5N1. Lymphopenia means low white blood cell count thrombocytopenia means low platelet count. A low platelet count would predispose one to bleeding, the severe cyanosis/blackness of the face is an indicator how how severe the ARDS interferred with the ability of the lungs to oxygenate.

It is better to look ahead and prepare than to look back and regret.

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by: Grace RN @ Wed Dec 13, 2006 at 16:05:59 PM CST

there isn't any report of 'turning black'

Grace, you know as well as I do that thrombocytopenia does not necessarily result in 'turning black'.  Think of any HUS patient.

Heliotrope cyanosis is also not being reported in these patients though one might expect to see it as the oxygenation goes down as a result of ARDS.  It may be that we're putting these patients on a vent to oxygenate them before they reach that level of cyanosis, and they may be dying of something other than purely oxygen starvation--such as perhaps right sided heart failure from trying to pump blood through ARDS lungs over several days.  But that is conjecture on my part.  Anyway, we're not seeing reports of people turning blue, and we're not seeing a whole lot of purpura either, even if the labs are saying that the level of early thrombocytopenia is a poor prognostic indicator.

I'm snarky tonight, so if this goes over people's heads would one of the other medicos please translate it to layperson please, I don't have the patience for it.

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Wed Dec 13, 2006 at 21:42:32 PM CST

[ Parent ]

Circulatory system support

Any guesses about the utility of taking supplements for circulatory support? Grasping at straws here but maybe taking some of these prophylactically could prepare the system to better endure trauma.

Bilberry, Inhibition of histimine induced capillary hyperpermeability and protection from capillary fragility.

Aescin, the active ingredient in Horse Chestnut seed, tones up the walls of the veins. It also relieves swelling by stopping excessive leakage through the walls of the capillaries (the tiny vessels that deliver blood to the tissues).

Rosemary, Used internally for digestive problems. Externally for cirulation disorders. Volatile oil is antibacterial and antifungal. May reduce capillary permeability & fragility. May reduce Acute Respiratory Distress Syndrome (Parnham and Kesselring 1985).

Pycnogenol used in people with chronic venous insufficiency is reported to reduce edema and pain.

Shepard's Purse, Relieves vascular leakage and enhances artery wall barrier. Taken internally for menstral bleeding. Externally applied for nosebleeds. Hypotensive effect.

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by: fredness @ Wed Dec 13, 2006 at 16:49:53 PM CST

JWB on PFI found this very very cool article- with pictures of cyanosis

Download the 40 pages, chapter 3 as a pdf

influenza.sph.unimelb.edu.au/data/S0001/chapters/P1_chap_3.pdf 

THE CLINICAL FEATURES OF THE INFLUENZA EPIDEMIC OF
1918-19.
BY
HERBERT FRENCH, C.B.E., M.D., F.R.C.P.

JWB said

"Here are very detailed (an lengthy) observations written first hand from a doctor that had thousands of cases. He writes about the differences in the waves, (he believed the minor epidemics during 1916 and 1917 were in fact part of 1918), different symptoms, treatments, etc. He details different effects on the various systems and organs, (he performed hundreds of autopsies)

influenza.sph.unimelb.edu.au/data/S0001/chapters/P1_chap_3.pdf

excerpts

This one is downright scary...

"Delirium and Coma.
Delirium and coma occurred often enough amongst the bad cases, but far more striking than their occurrence was their entire absence almost to the very end in so many instances. Big strong men, heliotrope blue and breathing 50 to the minute, obviously dying, would be fully conscious, talking rationally on almost any subject, relatively clear-headed to within half-an-hour of death ; often not realising in the least how dire their condition was. ..."

other excepts...

"... the rate of spread from one to another being remarkable.The patient would be seized rapidly, or almost suddenly, with a sense of such prostration as to be utterly unable to carry on with what he might be doing ; from sheer lassitude he would be obliged to lie down where he was, or crawl with difficulty back to bed so that barrack rooms which the day before had been full of bustle and life, would now be converted wholesale into one great sick room, the number of • sick developing so rapidly that the hospitals were, within a day or two, so overfull that fresh admissions were impossible and the remainder of the sick had to be nursed and treated where they were. ....

....Headache, especially of that type in which the head does not ache so much when it is kept still, but aches badly when there is a change of posture such as when the head is rolled from side to side, or some effort of coughing is made, was prevalent in many cases....

....Towards the end of a severe case coughing and expectoration would be entirely absent from sheer weakness of the sufferer and his inability to cough at all.The rate of breathing became accelerated out of all proportion to the physical signs; in the worst cases the respiration rate would rise to 40, 50, or even 60 to the minute, and yet without any particular evidence of respiratory distress;....

.... The Heliotrope Cyanosis. The facies, at first flushed and red, with a peculiar drooping of the eyelids giving a weary look, shown in Plate 1, might remain purely red throughout, but in nearly half the cases affected by the pulmonary complications the red tint rapidly changed to one of progressive cyanosis, depicted in Plates 2 and 3. It was] when this dreaded heliotrope cyanosis appeared that one knew that the prognosis had now altered so completely that the patient was almost certain to die ; a small percentage of cases managed to recover, even after the cyanosis had de-veloped, but the great majority succumbed, and it was amongst cases of this type that the great mortality of the epidemic occurred.There were, of course, cases which died without the cyanosis being pronounced, but in going round a large ward one could, without examining the patients at all beyond looking at their countenances, pick out those who were going to die with almost uniform certainty by reason of their colour alone.It was not by the temperature chart nor by the physical signs in the chest, nor by feeling the pulse that one could tell the serious cases so well as one could by their colour; the cyanotic tint might be definite in a patient who was complaining little, who was taking his liquid nourishment well, was taking an intelligent interest in his surroundings, answering questions promptly and clearly, and in no way— except by his colour—indicating that by the next day or the day after he would almost certainly be dead.....

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by: clark @ Thu Dec 14, 2006 at 03:03:40 AM CST

[ Parent ]

BF seen as hemmoragic fever

I recall a number of BF cases being misdiagnosed at first as hemmoragic fevers... I remember remarking to my husband how horrifically this disease must present if doctors made this mistake and that it must not look like the regular flu at all. I IRC, one case, there was an almost stubborn clinging to a diagnosis of a *combination* of bird flu and hemmoragic fever in the same patient, once the BF was definitively diagnosed. The doctors couldn't seem to bring themselves to believe this was "just the flu."

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by: Northstar @ Thu Dec 14, 2006 at 09:21:36 AM CST

[ Parent ]

Blue or Black?

Thank you Clark for bringing all the interesting sources of information, especially the last document-
http://influenza.sph...
"The Clinical Features of the Influenza Epidemic of 1918"

It is a 49 page chapter, but I recommend anyone to read it. This doctor performed autopsies on hundreds of young people. It is disturbing to think how many parents outlived their young adult children, a fate I do not want to experience.

There seems to be confusion about the two different discolorations:
*Cyanosis- caused by lack of oxygen by the lung congestion, starts on the lips, ears and fingernails before the whole complexion becomes bluish.
*Thrombocytopenic purpura- caused by clots and internal bleeding, which can appear as dark rash splotches, and severe damage can cause dead tissue to turn black.

The above document, on page 80, said that purpura was rarely seen in 1918. Most of the dead showed cyanosis. There was often nosebleeds and bloody sputnum, but without apparent skin purpura. That was then, but we don't know what is happening now with H5N1, from the reports. I see listed thrombocytopenia in the majority of cases, but that doesn't mean the people showed purpura spots, just that their platelet count is affected. There was a report of one Thailand case being mistaken for hemorrhagic fever.

I find this graph interesting-
http://www.who.int/w...
The length of time between onset of symptoms and death can range from 4 days to 30 days. ARDS and cyanosis can occur from either viral pneumonia or the secondary bacterial pneumonia. Some patients appear to be turning the corner and recovering from the first 7-10 days of flu, then succumb to the second whammy of bacterial infection in the second and third week. In this graph, out of 110 fatalities, 62 died within the first 9 days of illness. 48 died after 10 days to near 30 days of illness. These latter cases died under intensive care treatment: ventilators, IV, antibiotics; during a full pandemic most people will not receive this kind of hospital care. What would be the death rate with no hospitalization? 80%??

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by: NJ. Preppie @ Thu Dec 14, 2006 at 14:11:17 PM CST

JWB says all 10 chapters are available- 200 pages

JWB on PFI said- "More good news. It appears 10 chapters are available for a total of nearly 200 pages.

I wish I could stay home today and read this. It's fascinating!"

This is how I did it.

http://influenza.sph...

Which gives you the History of Influenza.

I assume just keep changiong the chapter #s and download

ie

http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...
http://influenza.sph...

I checked- it works!

My hat off to JWB from PFI!!

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by: clark @ Thu Dec 14, 2006 at 18:06:01 PM CST

[ Parent ]

REPORT ON THE PANDEMIC OF INFLUENZA 1918/9- by HERBERT FRENCH

More from JWB from PFI

His/her link will connect you to about 600 pages of information. This is a much better link to much more information than what I posted previously. The book has 3 parts- I only linked to part 1!!

"I backtracked the web address and found the main page for the book. It list the table of contents, and it has a searchable feature to it. You can also download the entire book as one file (15MB) from here:

http://influenza.sph...

I'll copy this post over to the old Fluwiki."

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by: clark @ Fri Dec 15, 2006 at 14:51:12 PM CST

[ Parent ]

Wow- thanks clark

this does make good reading - I will have to wait until this evening to read it all through

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Fri Dec 15, 2006 at 15:10:10 PM CST

[ Parent ]

HI NJ Preppie

The dead in New Zeand were turning black. I know that TPTB went out of their way to keep this information from the public. Noone was publicly saying "the corpses are all black"- The papers don't say it. The medical journals don't say it. but when you read the interviews with old timers who lived through Black November, they almost all mention the color of the dead.

Check out the tone of this little bit of information. It is like they had discovered the Da Vinci Code or something. Why is the blackness of the victims such a "only those who studied Latin are allowed to know this"

It is a big secret.

http://yaleglobal.ya...

In December 1979, the British Medical Journal published a letter from an army physician that had laid undiscovered in a trunk in Detroit for 60 years. In the 1918 letter, the doctor who was attending to soldiers in Boston during the devastating pandemic that year described in graphic detail how they were dying from the flu: 'Two hours after admission they have the mahogany spots over the cheek bones and a few hours later you can begin to see the cyanosis extending from the ears and spreading all over the face, until it is hard to distinguish the colored man from the white.

'It is only a matter of a few hours then until death comes and it is simply a struggle for air until they suffocate.' (Cyanosis is a bluish or purplish tinge to the skin.)

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by: clark @ Thu Dec 14, 2006 at 18:17:27 PM CST

[ Parent ]

do you want me to post plates 1-3? n/t

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by: DemFromCT @ Thu Dec 14, 2006 at 18:20:37 PM CST

[ Parent ]

of course, post them!

Why isn't this thread on the front page of the FluWikie? And don't tell me everything here is fair.

The info that JWB found is important. The discussion about Lymphopenia and thrombocytopenia is worth talking about- even if you can't eat it.

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by: clark @ Thu Dec 14, 2006 at 18:48:04 PM CST

[ Parent ]

Clark - please take a moment

to read the email I just sent you ;-)

Eat pudding first - who know's what might happen next! - Anon

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by: AnnieB @ Thu Dec 14, 2006 at 19:09:24 PM CST

[ Parent ]

platelet info

I posted a portion of the ICU Book's chapter on platelets here, for anyone who'd like to read some of the basic clinical information about it:

http://www.newfluwik...

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Thu Dec 14, 2006 at 18:14:07 PM CST

the cytokine storm and thrombocytopenia / lymphopenia

I am guessing that the cytokine storm is the cause of the thrombocytopenia and lymphopenia in H1N1 and N5N1 victims.

"What is a Cytokine Storm?
From Anna Spector

Definition: A cytokine storm is an excessive immune response that is thought to be the most deadly complication of H5N1 bird flu. The 1918 pandemic flu, also originally an avian influenza, also seemed to have sparked a cytokine storm in the body.

The term, cytokine storm, is not scientific and is simply used to describe the result of a massive immune response that releases huge amounts of cytokines, normally meant to fight infection, in the system. The over reaction leads to excessive inflammation and damage to the lungs which causes the death of victims infected with H5N1 bird flu. Nature Medicine published an article in September 2006 authored by Menno de Jong that supports the hypothesis that the cytokine storm is caused by the rapid replication of the H5N1 bird flu virus.

Studies of the 1918 pandemic flu, the H1N1 virus that also originated in birds, show that patients also died of the result of an exaggerated immune response.
Sponsored Links

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Bird Flu: The FactsIs a pandemic coming? Read about it free in award-winning Cosmos Magwww.CosmosMagazine.com

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Doctors who did autopsies on some victims of the 1918 pandemic flu were shocked to discover that the lungs of the victims were completely saturated with fluids. Normal, healthy lungs are light and flexible, ready to expand and contract as we breathe, but diseased lungs full of fluids are heavy with liquids and unable to absorb oxygen.

After a study published in Nature Medicine in September 2006, researchers believe treatments suppressing the immune response may save more bird flu patients than and other anti-viral drugs.

Examples: Sources:

  * Helen Pearson. Nature News. September 8, 2006.
  * Richard Knox. NPR News. February 4, 2004.
  * Center for Disease Control. Last modified October 7, 2005.
  * CIDRAP News. November 16, 2005.

Updated: September 18, 2006

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by: clark @ Fri Dec 15, 2006 at 22:44:45 PM CST

[ Parent ]

who is anna spektor?

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Sat Dec 16, 2006 at 00:30:17 AM CST

[ Parent ]

Anna Spector

http://birdflu.about...

Anna Spector is the About.com guide to bird flu, also known as avian flu. One of the topics she discusses is the H5N1 subtype of the Influenza A virus which can jump from birds to humans and is commonly referred to as bird flu. Spector is a freelance writer and has lived in many different countries with her husband, MD/MPH, who is an infectious diseases advisor for Doctors Without Borders (MSF).
Experience:
Freelance writer and translator (Spanish-English) for conservation and humanitarian organizations offering medical assistance, Spector originally studied to be a research scientist. She was an undergraduate research assistant at the University of California at Berkeley, completed an internship at the Smithsonian Environmental Research Center, and worked as a research assistant at Montana State University, Bozeman. She has lived and worked in Poland, Colombia, Bolivia and Spain.
Education:
Spector received her masters of public health (MPH) degree with a focus on Environmental Health from Tulane University School of Public Health and Tropical Medicine and a bachelor's degree from the University of California, Berkeley in plant biology. Courses such as risk assessment, community health, genetics, molecular and cell biology, toxicology and epidemiology enable her to understand the issues surrounding avian influenza. She took a field ornithology course at Montana State University Bozeman. She is fluent in Spanish, speaks some Polish and Catalan and is able to read in French.
From Anna Spector:
Bird flu has been particularly interesting for me to follow because it remains a great unknown. No one really knows if this is the next pandemic flu or not. Living standards, personal hygiene habits, agricultural practices, cultural beliefs and the behaviour of the virus all come together to spread a disease or to contain it. The subject of bird flu has led to many discussions between myself and my husband, an MD/MPH and infectious diseases advisor for the international medical humanitarian aid organization, Doctors Without Borders. We both agree, as supporters of public health, that it is always better to prevent a disease than to treat it. The road to prevention always begins with being well informed, so on this site, I aim to provide you with useful and reliable information.

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by: clark @ Sat Dec 16, 2006 at 02:05:22 AM CST

[ Parent ]

I must have graduated before she started there. n/t

medical information provided is for discussion purposes only and should not be construed as medical advice. if you believe you have a medical problem, consult your practitioner.

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by: Lisa the GP @ Sat Dec 16, 2006 at 02:15:08 AM CST

[ Parent ]

reposting a post by Gizzey on CE

http://www.curevents...

"Interestingly and it is only anecdotal but about a year ago. I was talking to my granny about AF.
Off course she dismissed it as nonsense and the internet being evil comments appeared.
There was no reasoning with her, so I started to talk about the "Spanish flu' of 1918"
She said " 1918 was a bad year in our family, for deaths. We lost over half but that was because of the war and the Black flu' and galloping pneumonia. Not that Spanish flu'."

Just found it interesting,reading this thread. I hadn't given it another thought at the time.
I will question her tomorrow.
Maybe we shouldn't always be so quick to dismiss what we hear. History is only as good as it's writers and is often re-written by the re-writers."

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by: clark @ Tue Jan 09, 2007 at 14:43:43 PM CST

use of steroids (prednisolone?)

http://search.japant...

"In reports about people who died from an infection of bird flu, the virus entered the blood and spread throughout (the body). The cause of death was multiple organ failure, and there was hemophagocytic syndrome," Kashiwagi said.

There are two types of influenza drugs, which are either swallowed or inhaled.

"For hemophagocytic syndrome, the injection of immune-suppressing drugs and steroids should be considered," he said.

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by: clark @ Fri Jan 12, 2007 at 18:35:55 PM CST

Dogs turn purple in Indonesia

Cimahi possible infected dead dog
27/01/2007Ikut died with 13 Positive chickens Flu Burung
in Cimahi, the Virus H5N1 was expected Serang Anjing

CIMAHI, (GM).
- At Least 13 chickens belonging to the resident RT 03/RW 18 Kel.
Cibabat, Kec.
Cimahi North, the Cimahi City was stated postif bird flu.
Belasan this chicken died suddenly in a beruntun manner this Sunday.
It was startling, a dog that one pen with this chicken took part in dying and being it was suspected attacked by the virus H5N1.
Although being not yet checked, but the official could confirm that this dog was affected by bird flu because of dying suddenly and the other clinical sign then almost was the same as the bird flu virus, like breathless and turned blue in several of his body parts.
Moreover, this dog died after several chickens that one sometimes by him was stated positive bird flu and died suddenly.
To prevent the spreading of the bird flu virus in this area, the official of the health of the animal and the Co-operative of the economic Service (Disperekop) the Cimahi City as well as the resident agreed to destroy the chicken and the available poultry animal.
On Friday (26/1) approximately struck 13.30 WIB, at least 47 tails of the poultry that consisted of birds, the duck, and the chicken were destroyed.
According to the Section Head the Health of the Disperekop Animal, Drh.
Suyoto, he has sent the sample of dog blood that died suddenly to be checked in the laboratory and results could be known in a few days.
"We could not check further because the dog carcass has been buried by the resident."
But, the clinical sign because of the death of the dog it was suspected was affected by bird flu, said Suyoto.
He said, very rare the bird flu virus attacked the dog.
The case of the spreading of the bird flu virus to the dog happened in Surabaya.

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by: clark @ Sun Jan 28, 2007 at 00:43:50 AM CST

Influenza2 found and translated the dog article

N/T

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by: clark @ Sun Jan 28, 2007 at 01:08:15 AM CST

[ Parent ]