How did swine flu kill a healthy boy?

Antioch kindergartner's death leaves parents and doctors without answers By Chas Sisk • THE TENNESSEAN • September 14, 2009 The most remarkable thing about the death of Max Gomez was that it could happen at all. Going into the last weekend in August, the Antioch 5-year-old was an energetic, independent kindergartner excited to be starting elementary school. Less than four days later, he was dead. "Max had gotten sick in the past. He'd had strep and ear infections, but he always came through," his mother, Ruth Gomez, recalled in an interview with The Tennessean last week. "But this time, everything happened so fast." The death of Max Gomez, an otherwise healthy boy who became the state's third fatality from swine flu nearly two weeks ago, could hold clues as to why a usually mild disease can sometimes turn deadly. Ruth Gomez described Max's flu as progressing extraordinarily quickly — from a fever on Saturday to an apparent recovery on Sunday to hospitalization and death on Monday. More than 1 million Americans are believed to have contracted H1N1 influenza, or swine flu, but only about 9,000 people, less than 1 percent of the cases, have gotten sick enough to require hospitalization. Fewer than 600 have died, according to figures published earlier this month by the Centers for Disease Control and Prevention. Of those, Max Gomez's case may be part of an even rarer group, in which the disease claimed the life of a child whose medical history gave no hints that he was vulnerable to swine flu. State and local health officials say they are still conducting tests to determine how Max, an inquisitive boy who loved fishing and outings with his church group, could have died from the disease. Until those tests are complete, they say they cannot determine whether any undiagnosed conditions or infections played a role in his death. There is little evidence that the boy did not get medical treatment quickly enough, or that doctors did not do all they could to save him. Instead, it appears that Max succumbed to an unusual combination of circumstances that resulted in tragedy. "Life is so fragile," Ruth Gomez said. "You can never know. You never know what could happen tomorrow." 'A good kid' The first few weeks of August were exciting times for Max, who was born in Nashville and had lived with his family off Bell Road for three years. He had started class at Henry Maxwell Elementary School, and unlike many children his age, Max embraced the chance to be independent. While some kindergartners let go of their parents' hands in tears, Max begged his mother to let him ride the school bus, and when his mother insisted on driving him instead, he begged her again to let him walk from the school's front door to the classroom on his own. In the classroom, Ruth said, Max was already a leader, offering to translate his classmates' Spanish for his teacher. "He really was a good kid," Ruth said, sitting in the family's immaculate living room, with peace lilies and memorials to Max clustered all around. "He was very happy, and he was very helpful. He had a good heart." When he fell ill on the weekend of Aug. 28, Ruth and her husband, Marco, saw little to fear. Max woke up with a fever that Saturday — a fever that peaked at just over 102 degrees, his mother recalled — but he otherwise seemed energetic. His parents suspected it was a routine childhood illness, an ear infection or a sore throat, one that would get better with a dose of Tylenol and rest. Instead of attending their Seventh-day Adventist Church in Smyrna, the family decided to stay home from church that day, just to be safe. By Sunday, Max's fever had subsided. To be cautious, the family decided not to let Max join a zoo trip with his church group, the Eager Beavers, but Ruth recalled he was playful that day and showed ample signs of recovery. Monday, however, began worrisomely. Max's fever returned, and he had chills. Ruth and Marco, an independent contractor, couldn't afford health insurance for themselves, but they had enrolled Max and his two younger sisters in TennCare, the state's health insurance program for low-income children, pregnant women and the disabled. Ruth took Max that day to a walk-in clinic in Antioch, where he was seen by a doctor and released. But by the time Marco came home from work at 5 p.m., Max's perpetual energy had given way to unrelenting fatigue. The family rushed Max to Monroe Carell Jr. Children's Hospital at Vanderbilt, where he was admitted around 6 p.m., Ruth recalled. The doctors seemed to sense the urgency of Max's case almost immediately. Still, he was dead less than three hours later. "This happened so fast," Ruth said. "At the beginning, we couldn't believe it, and looking back, we did question why, but we just feel like everything happens for a reason, that hopefully other people would learn from this. And we're doing OK as far as spiritually." Tests are being run An autopsy has been performed, but test results will not be ready for about two months, medical officials said. Until then, they can only speculate as to why the virus would have claimed the life of Max, a child who seemed so unlikely to succumb to the illness. "To answer that, you have to just look at those (cases) that seem like lightning bolts," said Dr. Tim Jones, the state epidemiologist. Earlier this month, the Centers for Disease Control released a bulletin on the first 36 children in the United States to die from swine flu, a group that does not include Max Gomez. The CDC found that two-thirds of those children had an underlying condition that made them more vulnerable to swine flu. These include epilepsy, muscular dystrophy, asthma or any other disease that suppresses the immune or respiratory systems. Max Gomez had not been diagnosed with any chronic diseases, his mother said. Instead, he appeared to fall into the remaining one-third of children who die from the disease, a group that scientists are still trying to learn more about. One possibility is that H1N1 could be exacerbated by a bacterial infection. All six of the children the CDC studied who were over 5 years old but did not have a chronic medical condition tested positive for a bacterial infection in addition to swine flu. Health officials said they did not know enough about Max Gomez's case to say whether a bacterial infection contributed to his death. But they did say that when influenza combines with a bacterial infection, such as pneumonia, the patient often follows a pattern in which his symptoms start to subside but then suddenly worsen. That pattern — which includes symptoms such as vomiting, chest pain, a racing pulse, breathing trouble, bluish skin or trouble staying awake — is an indication that the flu has turned deadly, and it means a sufferer should talk to a doctor immediately. "What you expect from ordinary flu is that it starts off bad and gets better," said Dr. Bill Paul, Metro's health director. "If that's not the case, it's worth a call." 'We hope we can learn' Ruth Gomez said the family has been trying to move on from Max's death. She said she has long encouraged her friends, even those without medical insurance, to see a doctor when their children fall ill, advice that she recommends with even more urgency now. The family, she said, has been drawing comfort from their church and their faith that Max's spirit lives on. "We have hope that we're going to see him again," she said. Doctors, meanwhile, hope to solve the mystery of Max's death, in the hope of helping other families avoid the same pain. "It is a tragedy," Paul said. "There is a young, healthy kid who is no longer with us. We hope we can learn lessons from it."