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In our series, the most frequent pneumonia patterns observed during S-OIV (H1N1) virus were interstitial changes and patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones. CT, performed in severely ill patients, confirmed the ARDS identified with chest X-rays, better depicting the features and extent of lung abnormalities.

IntroductionA new Influenza A virus H1N1 appeared in March-April 2009, and thousands of cases are being reported worldwide. In the initial months, several imported cases were reported in many European countries, while some countries reported local chains of transmission. We describe the first cluster of in-country transmission of the new Influenza A H1N1 which occurred in Italy, involving 3 patients.Case presentationPatient 1, a 11-year-old male child developed fever, cough, and general malaise 4 days after returning from a travel to Mexico. Some days later, the 69-year-old grandfather (patient 2), who did not travel to Mexico, and the 33-month-old brother (patient 3) of patient 1 developed mild influenza symptoms. PCR tests resulted positive for Influenza A, and sequence analysis confirmed infection with the Influenza A (H1N1) strain for all three patients. Some problems were experienced in the administration of chemoprophylaxis and therapy in the patient 3. The chemoprophylaxis policies in other family members are described, too.ConclusionSome interesting facts emerge from the analysis of this cluster. The transmission of Influenza A H1N1 virus seems to be dependent on strict contacts. Patient 2 and patient 3 did not take the chemoprophylaxis properly. The problems in the administration of chemoprophylaxis and therapy to patient 3 suggest that in infants specific individual-based strategies for assuring the correct administration are advisable.

In replyWe fully agree with Costantino and colleagues that differences in baseline characteristics may confound the results of a randomized controlled trial. Therefore, it is important to stress that the detailed description of demographic variables, symptoms, physical examination, vital signs, and laboratory analyses clearly showed that the BNP group and the control group were well matched in the B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study. 1,2 Therefore, it is appropriate to conclude from the BASEL data that BNP testing is cost-effective in patients with acute dyspnea.Costantino and colleagues argue that additional baseline variables including arterial blood gases and number of breaths per minute could have revealed a significantly different level of clinical severity. However, as suggested by the similarities in all other baseline characteristics, arterial blood gases and number of breaths per minute were also comparable in the BNP group and the control group in the BASEL study: PaO 2 , 9.3 vs 9.3 kPa (P = .99); PaCO 2 , 5.6 vs 5.5 kPa (P=.67); pH, 7.4 vs 7.4 (P=.74); and 24 vs 23 breaths per minute (P= .39).We disagree with Costantino and colleagues that exclusion of those patients admitted to the intensive care unit would provide valid insights. Intensive care unit admission of patients presenting with acute dyspnea to the emergency department is a result of initial disease severity and the response to initial therapy. This aspect is particularly evident when considering that about 40% of patients admitted to the intensive care unit were admitted after several days of therapy in a regular ward.