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Infections of the Upper Respiratory Tract Cynthia L. Gibert, M.D. Washington VA Medical Center 10/2/98 Upper Respiratory Infections • Upper respiratory tract infections are the most common human affliction. • Major share of time lost from work and school. • Most common cause of antibiotic abuse. 10/2/98 Upper Respiratory Infections • • • • 10/2/98 Influenza Epiglottitis Sinusitis The Common Cold Influenza • Virus isolated in 1933 • A major cause of morbidity and mortality 10/2/98 Spanish Flu Pandemic of 1918 • Sept. - Nov. 1918 • 20-40 million deaths • More Americans died than in the WWI, WW2, Korea, Vietnam • 1st case Camp Fuston, Kansas - 3/4/18 10/2/98 Influenza A Pandemics 1918 - 1919 Spanish H1N1 1957 - 1958 Asian H2N2 1968 - 1969 Hong Kong H3N2 10/2/98 Influenza A 13 Hemagglutinin subtypes 9 Neuraminadase subtypes 10/2/98 Epidemiologic Characteristics • • • • • Pandemics Epidemics Endemic Seasonal Age 10/2/98 Worldwide - antigenic shift Local - antigenic drift Sporadic Winter months - abrupt Infection: children > adults Mortality: adults > children Pathogenesis • Virus replication: 24 - 72 hours • Virus excretion: 3 - 7 days • Antibodies to HA, NA subtypes 10/2/98 Clinical Picture of Influenza Chills Fever Myalgias Cough Coryza Malaise 0 10/2/98 1 2 3 4 5 6 7 8 Secondary Bacterial Pathogens • S. pneumoniae • H. influenzae • S. aureus - Toxin Shock Syndrome 10/2/98 Reye’s Syndrome • • • • 10/2/98 Post influenza B Encephalopathy Hepatic dysfunction Elevate NH3, LFTs, CPK Influenza Vaccine Trivalent vaccine • A/Beijing/262/95-like (H1N1) • A/Sydney/5/97-like (H3N2) • B/Harbin/07/94 10/2/98 Indications for Vaccine • • • • • Elderly (age>65) High-risk* Household contacts Health-care personnel Pregnant women after 14th week High-risk: institutionalized, chronic heart or lung disease, diabetes, renal dysfunction, immunosuppressed, children on aspirin 10/2/98 Influenza Vaccine • Timing: October - Mid-November • Duration of immunity: start 1-2 weeks end 4-6 months 10/2/98 Diagnosis • Viral culture - tissue culture • Fluorescent-labeled murine monoclonal Ab - shell viral cell culture - viral Ag • PCR • CF - at onset and 2 weeks 4-fold-rise in Ab titre 10/2/98 Treatment of Influenza A Amantadine or rimantadine within 48 hours decreases fever and severity • Use in elderly or high risk • Hospitalized persons • Healthy adults 10/2/98 Prophylaxis of Influenza A • • • • • 10/2/98 Control of outbreaks in institutions Adjunct to late vaccination Immunodeficient - AIDS Vaccine contraindicated Home caregivers of high risk Epiglottitis - Acute Supraglottitis • A rapidly progressive and potentially fatal disease that must be recognized immediately. 10/2/98 Epiglottitis • Epidemiology: – most common in children 3-7 yrs. – decreased incidence because of Hib conjugate vaccine-stable rate in adults • Rate: – 1 in 1000-2000 pediatric admissions – 1 in 100,000 adult admissions 10/2/98 Differential Diagnosis of a Sore Throat • Peritonsillar abscess – sore throat, drooling, hoarseness, trismus, asymmetric tonsillar enlargement • Epiglottitis – Children: high fever, toxic, drooling, absence of cough – Adult: severe sore throat, dyshagia, fever • Infectious mononucleosis – tonsillar enlargement, exudative tonsillitis, pharyngeal inflammation, lymphadenopathy, splenomegaly, maculopapular rashes, petechial anathema • Parapharyngeal space infection – neck swelling after a sore throat 10/2/98 Epiglottitis - Pathogenesis • Haemophilus influenzae type b, S. pneumoniae, S. aureus, H. influenzae type non-b, H. parainfluenzae • Inflammation and edema of the epiglottis, arytenoids, arytenoepiglottic folds, subglottic area • Epiglottis pulled down into larynx and occludes the airway 10/2/98 Epiglottitis Clinical Manifestations • Abrupt onset - sore throat, fever, toxicity dysphagia, drooling, stridor, chest wall retractions • Beefy-red epiglottis • Inspiratory stridor and expiratory ronchi • Adults: muffled voice, drooling 10/2/98 Epiglottitis - Diagnosis • • • • 10/2/98 Visualization of epiglottis - “cherry red” Laternal neck x-rays: “thumb sign” WBC count > 15,000 left shift Blood cultures Differential Diagnosis • Viral croup - barking cough, less abrupt, less toxic • Bacterial tracheitis - S. aureus, H. influenzae, Strept., diphtheria • Aspiration of a foreign body 10/2/98 Therapy • Adequate airway - nasotracheal intubation • Adults - close observation • Antibiotics – cefuroxime, ceftriaxone – ampicillin resistance - up to 30% – chloramphenicol ? Corticosteroids - reduce postintubation inflammation 10/2/98 Prevention Rifampin - 20 mg/kg for 4 days • All household contacts if children under 4 • Daycare and nursery school contacts • Patient before discharge 10/2/98 Sinusitis - Clinical Findings • Viral URI, fever (50%), purulent nasal discharge, swelling, facial pain worse on percussion, headache, nasal obstruction, loss of smell • Children: facial pain, swelling, malodorous breath (50%), cough (80%), nasal discharge (76%), fever (63%), sore throat (23%) 10/2/98 Specific Clinical Criteria • Maxillary toothache, colored nasal discharge, poor response to nasal decongestants, abnormal transillumination, purulent secretions, cough > 7 days 10/2/98 Diagnosis • Nasal swabs not helpful • Transillumination of maxillary and frontal sinuses • Sinus x-rays: air-fluid level, complete opacity, mucosal thickening • CT scan not indicated - unless chronic infection, immunocompromised, suspected intracranial or orbital complication • Direct sinus aspiration 10/2/98 Factors that Predispose to Sinusitis • • • • 10/2/98 Impaired mucociliary function Obstruction of sinus ostia Immune defects Increased risk of microbial invasion Microbial Causes of Acute Maxillary Sinusitis PREVALENCE MEAN (RANGE) MICROBIAL AGENT (Bacteria) Streptococcus pneumoniae Haemophilus influenzae (nonencapsulated) S. pneumoniae and H. influenzae Anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus, Veillonella) Staphylococcus aureus Streptococcus pyogenes Branhamella (Moraxella) catarrhalis Gram-negative bacteria 10/2/98 Adults (%) 31 (20-35) 21 (6-26) Children (%) 36 23 5 (1-9) 6 (0-10) --- 4 (0-8) 2 (1-3) 2 9 (0-24) -2 19 2 Microbial Causes of Acute Maxillary Sinusitis MICROBIAL AGENT Viruses Rhinovirus Influenza virus Parainfluenza virus Adenovirus 10/2/98 PREVALENCE MEAN (RANGE) Adults Children (%) (%) 15 5 3 -- --2 2 Decongestants • Oxymetazoline HCL - TID for 48-72 hours • Pseudoephedrine HCL - only if allergic component • Nasal steroids for 2-3 weeks 10/2/98 Therapy Empiric antibiotics for 10 days • • • • 10/2/98 Amoxicillin/ampicillin TMP/SMX Cephalosporin - cefaclor, cefuroxime Azithromycin, clarithromycin Chronic Sinusitis • Symptoms for > 3 months Allergies, inadequately treated • Aerobes and anaerobes • ENT evaluation for endoscopy or CT • Antibiotics for 3-4 weeks 10/2/98 Caveat • Frontal sinusitis with tenderness and headache - thin barrier to CNS • Treat 10-14 days 10/2/98 Ethmoid and Sphenoid Sinusitis • Ethmoid sinusitis: edema of eyelids, tearing, retroorbital pain, proptosis • Sphenoid sinusitis: intractable headache, hypo/hyperesthesia of ophthalmic or maxillary branches of trigeminal n. (30%) 10/2/98 Cavernous Sinus Thrombosis • • • • • 10/2/98 Depressed mental status Meningeal irritation Ptosis, chemosis Proptopsis C.N. palsies - III, IV, VI Intracranial Complications of Sinusitis Complication • Meningitis • Osteomyelitis • Epidural abscess • Subdural empyema • Cerebral abscess • Venous sinus thrombosis • Cavernous sinus 10/2/98 Clinical Signs Headache, fever, stiff neck lethargy, rapid death Pott’s puffy tumor Headache, fever Headache, seizures hemiplegia, rapid death Convulsions, headache, personality change Picket-fence fever, rapid death Orbital edema, ocular palsies The Common Cold • Hippocrates: – rejected bleeding • Pliny the Younger: – kiss the hairy muzzle of a mouse • Ben Franklin: – not from exposure to cold/dampness; – close contact 10/2/98 Epidemiology • • • • • 10/2/98 65 million colds per year 150 million days of restricted activity 24 million medical visits 18 million days lost from work 22 million days missed from school Virology Over 200 viruses Virus type Andenoviruses Coronaviruses Influenza viruses Parainfluenza viruses Respiratory syncytial virus Rhinoviruses Enteroviruses 10/2/98 Serotypes 41 2 3 4 1 100+ 60+ Seasonal Variation • May-Aug • Sept-Dec - • Jan-Feb - • Mar-Apr - 10/2/98 Enteroviruses Mycoplasma, Rhinoviruses, Parainf. 1+2, RSV Adenoviruses, Influenza, Coronaviruses Parainf. 3, Rhinoviruses Transmission • • • • 10/2/98 Direct contact with infected secretions Hand - to - hand Hand - to environmental surface - to hand Spread by aerosoles Pathogenesis • Incubation period 1 - 4 days • Begins in posterior pharynx • Viral shedding 10/2/98 days 3 - 4 Clinical Presentation Dry, scratchy, sore throat Sneezing, nasal stuffiness, rhinorrhea Malaise, myalgia, headache Hoarseness, cough, low grade fever 10/2/98 Complications • Bacterial superinfection – Otitis media – Sinusitis – S. pneumoniae, H. influenzae, B. catarrhalis • Guillain-Barre Syndrome • Asthma attacks 10/2/98 Management • Throat culture, rapid Ag detection for group A strep • Diagnosis of influenza A, RSV 10/2/98 Use of Antibiotics • No benefit • Do not reduce bacterial complications • Emergence of resistant organisms 10/2/98 Aspirin and Influenza • Aspirin - prolonged excretion of rhinoviruses, influenza virus • Children - aspirin associated with Reye’s syndrome 10/2/98 Prevention • Vaccines – influenza A/B – adenoviruses types 4,7 • Intranasal interferon – rhinoviruses – nasal obstruction, bloody discharge 10/2/98