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The MKSAP Challenge

From the January ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

Editor's note: The following quiz contains questions and answers excerpted from MKSAP 12 Update, a new enhancement to the College's popular self-assessment program. For more information on MKSAP 12 Update, which was published in October, contact ACP-ASIM Customer Service at 800-523-1546, ext. 2600, or 215-351-2600. Look for more quizzes based on excerpts from MKSAP 12 Update in future issues of ACP-ASIM Observer.

Clinical scenario

A 28-year-old man with a history of severe asthma is evaluated because of fever and myalgias that began 18 hours ago. An influenza A outbreak is occurring in the community, and influenza infection is suspected in this patient.

Which of the following is an indication for treating this patient at this time?

A. Presence of symptoms for less than 2 days
B. History of severe asthma
C. Lack of availability of influenza vaccine
D. Presence of a positive viral culture that confirms the diagnosis


Answer: A

Educational Objective: Know the indications for using neuraminidase inhibitors in the treatment of influenza A infection.

Based on clinical trials, both oseltamivir and zanamivir have been shown to decrease the duration and severity of influenza symptoms. Both agents are approved for treating influenza virus infection if given within 2 days of symptom development. Since the patient's clinical illness is compatible with influenza and his symptoms began less than 2 days ago, he qualifies for treatment. However, he should not be given inhaled zanamivir because this agent has been associated with bronchospasm. He can take oseltamivir, which is an oral agent that has not been reported to induce bronchospasm.

Whether or not influenza vaccine is available does not affect the management of acute influenza, as a period of 2 to 3 weeks is usually required after vaccination for protective immunity to develop. In the appropriate epidemiologic setting, the clinical presentation of influenza infection is so characteristic that treatment may be started without a confirmatory viral culture, especially since waiting for culture results would exceed the 2-day period required for optimal treatment benefit.

Reference: Couch RB. Prevention and treatment of influenza. New England Journal of Medicine. 2000;343:1778-87.

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