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Upper Respiratory Infections: Insights and Management

Explore the common flu variants, pathogenesis, diagnostics, treatment options, and preventive measures for upper respiratory infections like influenza, epiglottitis, and sinusitis for better understanding and care.

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Upper Respiratory Infections: Insights and Management

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  1. Infections of the Upper Respiratory Tract Cynthia L. Gibert, M.D. Washington VA Medical Center

  2. 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.

  3. Upper Respiratory Infections • Influenza • Epiglottitis • Sinusitis • The Common Cold

  4. Influenza • Virus isolated in 1933 • A major cause of morbidity and mortality

  5. 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

  6. Influenza A Pandemics 1918 - 1919 Spanish H1N1 1957 - 1958 Asian H2N2 1968 - 1969 Hong Kong H3N2

  7. Influenza A 13 Hemagglutinin subtypes 9 Neuraminadase subtypes

  8. Epidemiologic Characteristics • Pandemics Worldwide - antigenic shift • Epidemics Local - antigenic drift • Endemic Sporadic • Seasonal Winter months - abrupt • Age Infection: children > adults Mortality: adults > children

  9. Pathogenesis • Virus replication: 24 - 72 hours • Virus excretion: 3 - 7 days • Antibodies to HA, NA subtypes

  10. Clinical Picture of Influenza

  11. Secondary Bacterial Pathogens • S. pneumoniae • H. influenzae • S. aureus - Toxin Shock Syndrome

  12. Reye’s Syndrome • Post influenza B • Encephalopathy • Hepatic dysfunction • Elevate NH3, LFTs, CPK

  13. Influenza Vaccine Trivalent vaccine • A/Beijing/262/95-like (H1N1) • A/Sydney/5/97-like (H3N2) • B/Harbin/07/94

  14. 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

  15. Influenza Vaccine • Timing: October - Mid-November • Duration of immunity: start 1-2 weeks end 4-6 months

  16. 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

  17. Treatment of Influenza A Amantadine or rimantadine within 48 hours decreases fever and severity • Use in elderly or high risk • Hospitalized persons • Healthy adults

  18. Prophylaxis of Influenza A • Control of outbreaks in institutions • Adjunct to late vaccination • Immunodeficient - AIDS • Vaccine contraindicated • Home caregivers of high risk

  19. Epiglottitis - Acute Supraglottitis • A rapidly progressive and potentially fatal disease that must be recognized immediately.

  20. 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

  21. 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

  22. 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

  23. 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

  24. Epiglottitis - Diagnosis • Visualization of epiglottis - “cherry red” • Laternal neck x-rays: “thumb sign” • WBC count > 15,000 left shift • Blood cultures

  25. Differential Diagnosis • Viral croup - barking cough, less abrupt, less toxic • Bacterial tracheitis - S. aureus, H. influenzae, Strept., diphtheria • Aspiration of a foreign body

  26. Therapy • Adequate airway - nasotracheal intubation • Adults - close observation • Antibiotics • cefuroxime, ceftriaxone • ampicillin resistance - up to 30% • chloramphenicol ? Corticosteroids - reduce postintubation inflammation

  27. Prevention Rifampin - 20 mg/kg for 4 days • All household contacts if children under 4 • Daycare and nursery school contacts • Patient before discharge

  28. 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%)

  29. Specific Clinical Criteria • Maxillary toothache, colored nasal discharge, poor response to nasal decongestants, abnormal transillumination, purulent secretions, cough > 7 days

  30. 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

  31. Factors that Predispose to Sinusitis • Impaired mucociliary function • Obstruction of sinus ostia • Immune defects • Increased risk of microbial invasion

  32. Microbial Causes of Acute Maxillary Sinusitis PREVALENCE MEAN (RANGE) Adults Children MICROBIAL AGENT (Bacteria) (%) (%) Streptococcus pneumoniae 31 (20-35) 36 Haemophilus influenzae 21 (6-26) 23 (nonencapsulated) S. pneumoniae and H. influenzae 5 (1-9) -- Anaerobes (Bacteroides, Fusobacterium, 6 (0-10) -- Peptostreptococcus, Veillonella) Staphylococcus aureus 4 (0-8) -- Streptococcus pyogenes 2 (1-3) 2 Branhamella (Moraxella) catarrhalis 2 19 Gram-negative bacteria 9 (0-24) 2

  33. Microbial Causes of Acute Maxillary Sinusitis PREVALENCE MEAN (RANGE) Adults Children MICROBIAL AGENT (%) (%) Viruses Rhinovirus 15 -- Influenza virus 5 -- Parainfluenza virus 3 2 Adenovirus -- 2

  34. Decongestants • Oxymetazoline HCL - TID for 48-72 hours • Pseudoephedrine HCL - only if allergic component • Nasal steroids for 2-3 weeks

  35. Therapy Empiric antibiotics for 10 days • Amoxicillin/ampicillin • TMP/SMX • Cephalosporin - cefaclor, cefuroxime • Azithromycin, clarithromycin

  36. Chronic Sinusitis • Symptoms for > 3 months Allergies, inadequately treated • Aerobes and anaerobes • ENT evaluation for endoscopy or CT • Antibiotics for 3-4 weeks

  37. Caveat • Frontal sinusitis with tenderness and headache - thin barrier to CNS • Treat 10-14 days

  38. 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%)

  39. Cavernous Sinus Thrombosis • Depressed mental status • Meningeal irritation • Ptosis, chemosis • Proptopsis • C.N. palsies - III, IV, VI

  40. Intracranial Complications of Sinusitis ComplicationClinical Signs • Meningitis Headache, fever, stiff neck lethargy, rapid death • Osteomyelitis Pott’s puffy tumor • Epidural abscess Headache, fever • Subdural empyema Headache, seizures hemiplegia, rapid death • Cerebral abscess Convulsions, headache, personality change • Venous sinus thrombosis Picket-fence fever, rapid death • Cavernous sinus Orbital edema, ocular palsies

  41. 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

  42. Epidemiology • 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

  43. VirologyOver 200 viruses Virus type Serotypes Andenoviruses 41 Coronaviruses 2 Influenza viruses 3 Parainfluenza viruses 4 Respiratory syncytial virus 1 Rhinoviruses 100+ Enteroviruses 60+

  44. Seasonal Variation • May-Aug - Enteroviruses • Sept-Dec - Mycoplasma, Rhinoviruses, Parainf. 1+2, RSV • Jan-Feb - Adenoviruses, Influenza, Coronaviruses • Mar-Apr - Parainf. 3, Rhinoviruses

  45. Transmission • Direct contact with infected secretions • Hand - to - hand • Hand - to environmental surface - to hand • Spread by aerosoles

  46. Pathogenesis • Incubation period 1 - 4 days • Begins in posterior pharynx • Viral shedding days 3 - 4

  47. Clinical Presentation Dry, scratchy, sore throat Sneezing, nasal stuffiness, rhinorrhea Malaise, myalgia, headache Hoarseness, cough, low grade fever

  48. Complications • Bacterial superinfection • Otitis media • Sinusitis • S. pneumoniae, H. influenzae, B. catarrhalis • Guillain-Barre Syndrome • Asthma attacks

  49. Management • Throat culture, rapid Ag detection for group A strep • Diagnosis of influenza A, RSV

  50. Use of Antibiotics • No benefit • Do not reduce bacterial complications • Emergence of resistant organisms

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