Be aware of misdiagnosis—Influenza A H1N1 in a pregnant patient with suspected COVID‐19

Short abstract

Following standard and transmission‐based precautions is essential in the differential diagnosis of COVID‐19 infection.

A 21‐year‐old woman (primipara) at 33 weeks + 6 days gestation was admitted to the Third Affiliated Hospital of Guangzhou Medical University on February 3, 2020. None of her prenatal screening results were abnormal. She complained of cold symptoms on January 29, 2020. Upon onset a fever of 39°C on January 31, she went to a local clinic, where her blood pressure was 170/110 mm Hg. Her white blood cell count was 10.92 × 10⁹/L, total lymphocyte count was 0.85 × 10⁹/L, hemoglobin was 9.8 g/dL, and platelet count was 56 × 10¹⁰/L and acetaminophen was given. On February 2, the patient developed a cough with sputum and a fever of 38.8°C. Her serum parameters were as follows: ALT, 154 U/L; AST, 298 U/L; creatinine, 187 μmol/L; uric acid, 752 μmol/L; platelet count, 25 × 10¹⁰/L; urine protein, 2+. Computed tomography scan of chest showed pneumonia. She denied travel history to Hubei within 14 days. Thus, she was diagnosed with HELLP syndrome and pneumonia and was referred to our hospital with a mask. After suspected infection with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), the patient was quarantined. Nasopharyngeal swabs were collected for detection of SARS‐CoV‐2 using real‐time reverse transcription polymerase chain reaction (qRT‐PCR). The maternal vital signs and oxygen saturation were normal in the isolation unit, but the fetus distress appeared. Emergency Cesarean delivery was performed in a negative‐pressure room. A healthy female infant was delivered with weight 1960 g, Apgar scores 5 and 7 at 1, 5 min respectively. The mother was subsequently transferred to the isolation room in ICU for assisted ventilation and was given oseltamivir and cefoperazone on February 4. The chest images showed ground‐glass opacity and consolidation (Fig. 1). In the morning of February 5, her oxygenation index dropped to less than 200 from approximately 300 on Feb 4 with a high fever of 39.5°C. Her nasopharyngeal swabs were negative for SARS‐CoV‐2, but positive for influenza H1N1. Fiber bronchoscopy was performed sampling sputum. On February 6, the patient was extubated and continuously improved through ongoing medical management. The results of metagenomics next generation sequencing (mNGS) in balf indicated Staphylococcus aureus Infection.

Figure 1.

Chest radiograph (A) exudate in both lung fields on Feb 4 (B) perihilar lesions absorption and right subpleural consolidation on Feb 8; Chest CT (C) perihilar patchy ground glass opacity and consolidation on Feb 4 (D) peribilar ground glass opacity absorption with subpleural consolidation appeared on Feb 10.

In the early months of 2020, worldwide attention focused on the COVID‐19 pandemic. Pregnant women were considered susceptible to these respiratory infections and at risk of developing severe pneumonia. During the 2009 influenza A (H1N1) pandemic, there were 34 confirmed or probable cases and 6 deaths of the virus among pregnant women during the first month of the outbreak and six deaths of pregnant women during the first two months. ¹ This case was suspected COVID‐19 for her fever/respiratory symptoms, reduced lymphocyte counts and the imaging features. ² Epidemiological history was crucial but it was complex to investigate. Cases were diagnosed based on the WHO interim guidance ³ and confirmed depending on the pathogen testing. One study reported that among 53 patients with suspected COVID‐19, 20 were confirmed positive: 14 were positive at first RT‐PCR, 3 were positive at second RT‐PCR, and 3 were diagnosed using mNGS. ⁴ Thus, missed diagnosis and misdiagnosis are easy to occur in the early onset. Second PT‐PCR and mNGS detection may cost longer time, especially in rural areas like this case. Given the highly contagious of SARS‐CoV‐2, obstetricians should take personal protective precautions even though pneumonia may be caused by other pathogens until infection with SARS‐CoV‐2 is excluded.

Author contributions

He Fang: Methodology Formal analysis, Writing—original draft. Pan Xingfei: Data curation, Validation. Qiu Yingwei: Chest radiograph resources. Chen Dunjin: Conceptualization, Writing—review & editing.

Conflicts of Interest

There is no funds or conflicts of interest.