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Tuesday, October 22, 2019

What Do You Do When the Flu Turns Life-Threatening?

Posted By: Advancing Care

Quick thinking and coordinated care save a healthy teenager from a diagnosis that threatened her life.

By Melissa F. Pheterson

Rebecca Berak, of Poughkeepsie, was scheduled to get her flu vaccination on a Friday in December 2018. But the day before, the honors student came home from school beset with chills. Her mother, Kathie, assumed it was a stomach bug and took pains to keep her 13-year-old away from her 90-year-old mother.

At 2 a.m., Rebecca began to have trouble breathing. Her mother took her to an urgent care center, where she tested positive for influenza and received medication. Back at home, however, she vomited up the doses and fell asleep.

“During the night, Willow, our baby Dachshund, was lying across Rebecca’s hips as she slept on the couch and was making this strange whine that caught my attention. As soon as I touched Rebecca, I jumped back,” Kathie said.

The thermometer confirmed her fear: a 106-degree fever. Rebecca began to cough up blood, including thick clots that her mother later realized were pieces of lung tissue. They raced to the emergency room of a local hospital, where “they told me she was about to die,” Kathie recalls. “I said, ‘She’s a perfectly healthy kid — this isn’t happening.’”

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As the flu erupted into a case of necrotizing pneumonia, Rebecca’s body was thrown into sudden shock, acute respiratory failure and kidney failure. Her lungs began to fill with blood.

Rebecca was transferred by ambulance to Maria Fareri Children’s Hospital, a member of the Westchester Medical Center Health Network (WMCHealth), where Gary Tatz, MD, a member of the pediatric critical care medicine team, had the blood bank prepare the equivalent of two gallons of blood for resuscitation.

“Because we’re a Level 1 Trauma Center, we have massive transfusion protocols that allow us to prepare for patients who are in shock from severe bleeding,” says Dr. Tatz.

His team gave Rebecca five units of blood and plasma within minutes. “Once we stabilized her, including airway management, and she had acceptable vital signs, we raced her up to the Pediatric Intensive Care Unit (PICU),” says Dr. Tatz. There, she was placed on an oscillator to provide adequate breathing and oxygen support. By applying cardiorespiratory support via mechanical ventilation and fluid resuscitation, Dr. Tatz says Rebecca showed enough improvement to avoid the need for a heart-lung bypass machine.


Once Rebecca was out of imminent danger, it was time to address the infection.

“Rebecca’s flu illness quickly worsened due to a bacterial infection in her lungs, and it was this bacterial ‘super-infection’ that wreaked havoc,” says Sheila Nolan, MD, Chief of Pediatric Infectious Diseases at Maria Fareri Children’s Hospital. The bacterial infection caused a necrotizing pneumonia that was destroying Rebecca’s lung tissue. Dr. Nolan combined anti-flu medications with several bacterial antibiotics to treat the infections.

“We weren’t certain that Rebecca would survive,” Dr. Nolan adds, “but we knew that being young, strong and healthy might help her pull through.”

Three days after Christmas, Rebecca was transitioned from an oscillating vent (generally used for more severe pulmonary disease) to an A/C vent (a conventional ventilator), to accommodate a CT scan of her lungs. To have the test, she was temporarily taken off her medications, and she briefly woke up. “It was just a relief to know she was still in there,” recalls Kathie.

As her lungs and airway continued to heal over the course of weeks, doctors created a surgically placed hole in her trachea (windpipe), called a tracheostomy, to help her breathe. Finally, on April 8 — after spending six weeks in the PICU and 10 weeks in rehabilitation — Rebecca came home.

“What I remember most is the staff’s determination to get me walking again, to build my strength,” says Rebecca, who, after several months of hard work and home instruction, was able to pass her Regents exams in August and enter high school in September.

Rebecca was hospitalized in December, returned home in April and passed her Regents exams in August. She is now in high school.

“There was no margin for error or delay,” says Dr. Tatz. “It was an extraordinary situation, which required a coordinated effort among the Emergency Department, Pediatric Surgery team and the PICU. She was fortunate to be at the right place at the right time.”

How to foil the flu

Advice from Sheila Nolan, MD, Chief of Pediatric Infectious Diseases at Maria Fareri Children’s Hospital, a member of the Westchester Medical Center Health Network (WMCHealth).

The earlier your flu shot, the better. “Flu season typically starts at the end of November, but some strains can start earlier. The end of December — peak season for traveling — is when we see peak illness in this region. I recommend getting the vaccine before Thanksgiving, in October if possible. It takes a good two weeks before the vaccine offers protection.”

You’re never too healthy to need your flu shot. “People who have underlying conditions are at risk for more severe disease with the flu — but 50% of mortality in children with influenza is in otherwise-healthy kids.”

Don’t let your reaction deter you from getting it. “It’s true, you can get low-grade fever, mild aches and pains from the flu shot, but that’s your body’s immune response to the vaccine’s inactivated virus. The vaccine helps prevent the more severe complications and disease, like bacterial superinfection.”

Alternatives to the needle exist. “Besides the inactivated shot, there’s a live intranasal vaccine that’s a squirt of fluid in your nose.”

Recommendations for people with egg allergies have changed. “Unless you have an anaphylactic reaction to eggs, the flu shot is still recommended. The egg protein transmitted in the vaccine is exceedingly low. Plus, new preparations exist that are completely egg-free.”

I have a cold. Should I postpone my flu vaccine? Mild illness doesn’t mean you shouldn’t get your annual flu vaccine. If you have an acute moderate or severe illness, it is generally recommended to wait to receive the vaccine. It’s best to check with your doctor if you are not sure whether you should receive the vaccine.

Visit us at Maria Fareri Children’s Hospital, a member of Westchester Medical Center Health Network, to learn more. Advancing Care. Here.

Photos by John Halpern