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Parainfluenza Virus Case Study # 2 Galarah D Golanbar Christopher Kwon Vanessa Munoz Case study • A 13 month old child has a runny nose, mild cough, and a low grade fever for several days. The cough got worse and sounded like “barking”. The child made a wheezing sound when agitated. The child appeared well except for the cough. A lateral X-ray examination of the neck showed a subglottic narrowing. Background information • Parainfluenza virus (PIV) – Negative sense, single-stranded RNA virus – Varies in size and shape • Averaging in diameters of 150-300 nm – Account for a large percentage of pediatric respiratory infections, second to respiratory syncitial virus. – Major cause of croup – Divided into 4 types • Type 1 is the most frequent in children, followed by type 3 and type 2. • Type 4 is less likely to cause a severe illness. • Self- limited infection – Can manifest repeatedly throughout life Described Symptoms • Coryza – Symptoms of a common head cold • • • • nasal congestion runny nose Sore throat cough – Inflammation of nasal cavity mucous membrane, affecting upper respiratory tract • Viral croup – Inflammation of the larynx and upper airway • Results in narrowing of the airway – Characterized by a barking cough, inspiratory stridor, and a variable amount of respiratory distress that develops over a brief period. • Stridor – A high pitched, breathing sound caused by turbulent flow of air, usually caused by a blockage in breathing – Inspiratory stridor (a sound heard in inspiration through a spasmodically closed glottis) Described Symptoms • Retractions – Intercostal retractions: retractions of the chest cavity • The inward movement of the chest due to decreased pressure in the chest cavity. • Usually an indicator for difficulty in breathing • The virus will cause a diffused inflammation with erythema and edema in the tracheal walls that will affect the mobility of the vocal cords. – The subglottic region of the child’s upper airway is narrow. So, a small amount of edema will significantly restrict airflow. Other causative agents • Viruses from the Paramyxoviridae family – Mumps, measles, and respiratory syncitial virus (RSV) • Can also cause sporadic cases of croup • Adenovirus – Infection of the respiratory tract, as well as eyes, intestines, and urinary tract • Pneumonia – Inflammation of the lungs caused by bacteria, viruses, or other microorganisms – Leading cause of death in children worldwide • Influenza A and B – Both caused by viruses in the family Orthomyxoviridae Differential Diagnosis • There are several differential diagnoses listed: Acute Spasmodic croup laryngotracheobronc hitis Epiglottitis Bacterial tracheitis Peritonsillar abscess Retropharyngeal abscess Diphtheria Angioneurotic edema Burns or thermal injury Smoke inhalation Neoplasm or hemangioma Foreign body Acute laryngeal fracture Arnold-Chiari malformation Dandy-Walker malformation Laryngomalacia Subglottic stenosis Laryngeal papillomatosis Extrinsic obstruction by a vascular ring Parainfluenza virus : Current Diagnosis • Pulse Oximetry • Monitors oxygen saturation in the blood. • Used to evaluate the severity of the illness. • Laryngoscopy • Direct: An examination used to look inside the throat with a small camera. • Used in severe cases of parainfluenza virus infection. • Indirect: done with a small handheld mirror to look at the back of the throat. Techniques and Tests for Diagnosis • Diagnostic Techniques: – Radiographic Studies • Posteroanterior (PA) radiography of the neck – Only confirms 50% of cases http://aapredbook.aappublications.org/week/io tw092004.shtml --> Parainfluenza virus : Current Diagnosis • Lab tests: – Viral cultures • Requires several days to see the results. More helpful epidemiologically than clinically. – Immunofluorescence and enzyme immunoassay methods • Done in vitro and tests the nasopharyngeal washings of infected patients. – CBC: • Complete Blood Count measures: – Red blood cell (RBC), white blood cell (WBC), total hemoglobin in blood, hematocrit (fraction of blood composed of RBCs), and mean corpusular volume (MCV, which measures size of RBCs) – RNA amplification – Hemadsorption Final Diagnosis Treatment • No vaccine or direct treatment for the virus. Instead, treatment is focused on managing the symptoms. • Based on the severity of symptoms, mainly of croup: – Croup severity ranges from mild or moderate, to severe – Severity of the infection is based upon five factors: • Level of consciousness, Cyanosis, Stridor, Air Entry and Retractions Treatment • Analgesics • Ribavirin • Cool mist and oral intake of fluids – Common types of treatment, as can be done at home – Cool mist helps to soothe inflamed mucosa • Nebulized epinephrine – Used for moderate to severe croup patients to alleviate symptoms • Corticosteroids – Orally administered – To treat airway inflammation and edema • Heliox – Breathing gas composed of a mixture of helium and oxygen • Intubation – Rare, done only in severe cases References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. Viral Croup: A Current Perspective. Leung, A.K.C., Kellner, J.D., Johnson, D.W. Journal of Pediatric Health Care November/December (2004): 297-301. 2. Infections: Croup. Dowshen, S., Homeier, B.P. Nemours Foundation. May, 2005. 3. Parainfluenza virus infections. Vega, R.M. eMedicine from WebMD. Sept. 24, 2007. 4. Evaluation of Stridor and Wheezing. Holinger, L.D. Journal of Children’s Memorial Hospital, Chicago. Spring, 1998. 5. Definition of Human Parainfluenza Virus. (http://www.medterms.com/script/main/art.asp?articlekey=31631) 6. Viral Croup: A Current Perspective. Leung, A.K.C., Kellner, J.D., Johnson, D.W. Journal of Pediatric Health Care November/December (2004): 297-301. 7. Human Parainfluenza Virus Type 4 Infections: A report of 20 cases from 1998 to 2002. Billaud et al. Journal of Clinical Virology 34 (2005) 48–51. 8. Clinical courses of croup caused by influenza and parainfluenza virus. Peltola, V., Heikkinen, T., & Ruuskanen, O. The Pediatric Infectious Disease Journal 21 (2002) 9. Acute Epiglottitis. Jaffe, J.E. eMedicine.com by WebMD. (http://www.emedicine.com/Radio/topic263.htm) 10.Parainfluenza Virus. Parija, S.C., Marrie, T.J. eMedicine.com by WebMD. (http://www.emedicine.com/MED/topic1733.htm) References 1. 11.Concise Review for Primary-Care Physicians-Viral Croup: Current Diagnosis and Treatment by Julia Rosekranse, MD (http://www.mayoclinicproceedings.com/inside.asp?AID=3078&UID) 2. 12.Quest Diagnosis Laboratories test guide (2006). 3. 13. Fan J, Henrickson KJ: Rapid diagnosis of human parainfluenza virus type 1 infection by quantitative reverse transcription-pcr-enzyme hybridization assay. Journal of Clinical Microbiology 34:1914-1917, 1996. 4. 14. Gilbert LL, Dakhama A, Bone BM, et al: Diagnosis of viral respiratory tract infections in children by using a reverse transcription-pcr panel. Journal of Clinical Microbiology 34:140-143, 1996. 5. 15.Steele RW: Pneumonia in children: Current status of diagnosis and treatment. Journal of Respiratory Diseases 8:63-73, 1987. 6. 16.Sidwell RW, Huffman JH, Khare GP, et al: Broad-spectrum antiviral activity of virazole 1-b-dribofuranosyl-1,2,4-triazole-3-carcoxamide. Science 177:705-706, 1972. 7. 17.Steele RW: Antiviral agents for respiratory infections. Pediatric Infectious Diseases Journal 7:457-461, 1988. 8. 18. Cobian L, Houston S, Greene J, et al: Parainfluenza virus respiratory infection after heart transplantation: Successful treatment with ribavirin. CID 21:1040-1041, 1995. 9. 19.Gilbert B, Knight V: Biochemistry and clinical applications of ribavirin. Antimicrob Agents Chemother 30:201-205, 1986. 10. 20. Gelfand E: Ribavirin treatment of viral pneumonia in severe combined immunodeficiency. Lancet 1:732-733, 1983. 11. 21.Kairys SW, Olmstead EM, O'Connor GT: Steroid treatment of laryngotracheitis: A meta-analysis of the evidence from randomized trials. Pediatrics 83:683-693, 1989. 12. 22.Klassen TP, Feldman ME, Watters LK, et al: Nebulized budesonide for children with mild-tomoderate croup. N Engl J Med 331:285-289, 1994.