Clinical Cases

HomeProfessionalsClinical ResourcesClinical Cases ▶ A Pregnant Woman with Fever and Respiratory Failure
A Pregnant Woman with Fever and Respiratory Failure

Reviewed By Microbiology, Tuberculosis & Pulmonary Infections Assembly

Submitted by

Sonia Vishin, MD


Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Jody Hunt, MD


Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Keith Wille, MD

Associate Professor

Division of Pulmonary, Allergy and Critical Care Medicine

University of Alabama at Birmingham

Submit your comments to the author(s).


A 28-year-old white female at 29 weeks gestation, G2P1, presented to the emergency department with increasing shortness of breath and fever for 3 days. She also endorsed nausea, loose bowel movements and emesis for 2 days prior to admission. Prior to this, she was in her usual state of health. She denied cough, chest pain, joint pain, rash or hemoptysis. Her past medical history was significant for well-controlled asthma. However, over the last few days, she had been using her rescue inhaler up to 8 times a day. She denied any sick contacts. She had one previous full-term pregnancy and delivered vaginally, with no complications. Her family history was significant for both parents having hypertension and diabetes mellitus. Her father also had congestive heart failure. The patient smokes one pack of cigarettes per day but denies alcohol or illicit drug use. She is married and lives with her husband and child. Her medications at the time of admission included folic acid, prenatal vitamins, fluticasone/salmeterol and albuterol MDI as needed.

Physical Exam

On examination, the patient’s pulse was 94 beats per minute and regular. She had a temperature of 101.3 degrees Fahrenheit and a blood pressure of 98/31 mm Hg. Her oxygen saturation was 84% on 100% O2 by nonrebreather mask and had a respiratory rate of 32 breaths per minute. Cardiovascular exam revealed no murmurs. Respiratory exam showed bilateral crackles. Abdominal exam showed gravid uterus, otherwise unrevealing.


  • Serum chemistries were significant for a bicarbonate level of 18 mEq/L and creatinine of 1.5 mg/dl
  • Complete blood count was significant for WBC 12.5 x 103, platelet count 145 x 103, hemoglobin 9.4 g/dl. Differential count was 90% segmented neutrophils and 8% lymphocytes
  • Urinalysis showed 3+ blood, 1+ ketones, 1+ protein
  • Liver function profile was significant for AST 148, ALT 32
  • Rapid flu test was negative

Chest radiograph is shown in Figure 1.

She was intubated urgently for respiratory failure.  Based on the chest radiograph and lab studies, further work up was done, including bronchoscopy with bronchoalveolar lavage (BAL):

  • BAL fluid:
    • CMV culture negative
    • Viral culture negative
    • Viral respiratory panel positive for Influenza A
    • Legionella culture negative
  • Blood cultures negative
  • Urine Legionella antigen negative
  • Transthoracic echocardiogram – bilateral ejection fractions >55%, no vegetations, no significant valvular disease


Figure 1. Portable chest radiograph

Question 1

What is the most likely diagnosis?


  1. Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009-2010 flu season. Centers for Disease Control Website. Available from:
  2. Treanor JJ, Hayden FG, Vrooman PS, et al. Efficacy and safety of the oral neuraminidase inhibitor oseltamivir in treating acute influenza. JAMA 2000;282:1016-1024.
  3. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children-diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2009;48:1003-1032.
  4. Updated Interim Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season; Center for Disease Control Website. Available from:
  5. World Health Organization, Global Alert and Response; Oseltamivir Resistance in Immunocompromised Hospitalized Patients. Available from:
  6. Hurt AC, Holien JK, Parker MW, et al. Oseltamivir Resistance and the H274Y Neuraminidase Mutation in Seasonal, Pandemic and Highly Pathogenic Influenza Viruses. Drugs 2009;69:2523-2531.
  7. Summary of 2009 Monovalent H1N1 Influenza Vaccine Data- Vaccine Adverse Event Reporting System; Centers for Disease Control. Available from:
  8. Sym D, Patel PN, El-Chaar GM. Seasonal, avian, and novel H1N1 influenza: Prevention and treatment modalities. Ann Pharmacother 2009;43:2001-2011.
  9. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009;374:451-458.
  10. Saleeby E, Chapman J, Morse J, et al. H1N1 influenza in pregnancy: cause for concern. Obstet Gynecol 2009;114:885-891.