Upper and lower respiratory tract infectionsard
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Transcript Upper and lower respiratory tract infectionsard
Burden of Upper respiratory tract
infection (URI)
Significant morbidity and direct health care costs
Direct costs of $ 17 billion annually
Excessive use of antibiotics a major issue
Occasionally leads to fatal illness
Common cold - Definition
The common cold is a viral infection
upper respiratory tract, nose, and throat
More than 100 viruses can cause a common cold
signs and symptoms tend to vary greatly
Preschool children are at greatest risk of frequent colds
children average 8 per year, adults 3
Most people recover from a common cold
a week or two
The Common Cold - Causes
Etiologies
Rhinoviruses 30 to 35%
Coronaviruses about 10%
Miscellaneous known viruses about 20%
Influenza and adenovirus-30%
Presumed undiscovered viruses up to 35%
Group A streptococci 5% to 10%
Parainfluenza was the first respiratory virus isolated (1955)
Seasonal variation
Rhinovirus early fall
Coronavirus- winter
Transmission of Rhinoviruses
Direct contact is the most efficient means of transmission
40% to 90% recovery from hands
Brief exposure (e.g., handshake) transmits in less than 10% of
instances
Kissing does not seem to be a common mode of transmission
Transmission through droplet
dispersion
(Courtesy-American Assoc. for the Advancement Of Science)
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Molecular surface of a Human
rhinovirus, showing protein spikes
Risk factors
Cold viruses are almost always present in the environment
But the following factors can increase your chances of getting
a cold:
Age
Immunity
Time of year
Clinical characteristics
Incubation period 12-72 hours
Nasal obstruction, drainage, sneezing, scratchy throat
Median duration 1 week - but 25% can last 2 weeks
Pharyngeal erythema is commoner with adenovirus than with
rhino or coronavirus
Common Cold - Symptoms
Common symptoms are
sore throat
runny nose
nasal congestion
sneezing
Sometimes accompanied by
conjunctivitis
myalgias
fatigue
Sinusitis often present by CT scan; “rhinosinusitis” might be a
better term
Common Cold - Complications
Acute ear infection (otitis media)
Wheezing
Sinusitis
Other secondary infections
The common cold
Diagnosis and treatment
Main challenge is to distinguish between uncomplicated cold and
streptococcal pharyngitis or bacterial sinusitis
Marked exudate or pharyngeal erythema suggests
Streptococcal infection
Adenovirus
Diphtheria
Rapid antigen tests for group A streptococcus
Rapid techniques for influenza, RSV, parainfluenza
Treat with NSAIDs and whatever else your grandmother advises
A Rapid Strep Test kit
Acute sinusitis - Definition
Acute sinusitis
causes the cavities around your nasal passages to become
inflamed and swollen
With acute sinusitis, it may be difficult to breathe through
the nose
Acute sinusitis is most often caused by the common cold
Acute sinusitis - Causes
Acute sinusitis can be caused by:
Viral infection
Bacterial infection
Fungal infection
Some health conditions can increase the risk of getting a sinus
infection include:
Allergies
Deviated nasal septum
Other medical conditions
Nasal polyps or tumors
Tooth infection
Acute bacterial sinusitis
Epidemiological studies suggest 1 billion cases of viral
rhinosinusitis occur annually in the US
Of these 0.5 – 2 % are complicated by bacterial sinusitis
Acute sinusitis typically starts with viral infection that paves the
path for pathogenic bacteria
The major pathogens are Streptococcus pneumoniae and Haemophilus
influenzae
Nose blowing generates high intranasal pressures that deposit
bacteria into the sinus cavity
More common in adults than in children
Acute bacterial sinusitis - Causes
Community acquired bacterial sinusitis
S. pneumoniae
H. influenzae
S. pyogenes
Nosocomial sinusitis
Seen in critically ill, mechanically ventilated
S. aureus
Pseudomonas aeruginosa
Serratia marcescens
Fungal
Bacterial sinusitis - Clinical features
Clinical features
Sneezing
Nasal discharge
Facial pressure
Fever
Purulent drainage
Headache
Sinus imaging not routinely recommended
Chronic sinusitis
Chronic sinusitis
a common condition in which the cavities around nasal passages
(sinuses) become inflamed and swollen
for at least eight weeks, despite treatment attempts
Chronic sinusitis - Causes
Bacterial
Cultures show a variety of opportunistic pathogens including
anaerobes but problem is mainly anatomic, not microbiologic
Fungal
Suspect especially when a single sinus is involved
Numerous microorganisms can be isolated from patients with
chronic sinusitis
Mixtures of aerobic and anaerobic bacteria are common
The general conclusion at this time is that in most patients,
no single microorganism can be assigned a pathogenic role
In some patients, however, P. aeruginosa or S. aureus seems to
be clearly pathogenic
There are data suggesting roles for H. influenzae and
Moraxella catarrhalis in children
In these instances, especially in children, Streptococcus
pneumoniae and Haemophilus influenzae may be important
Numerous bacteria including gram-negative rods have been
isolated with patients with post-operative sinusitis
Acute pharyngitis
Inflammatory syndrome of the pharynx
Most cases are viral
Most important bacterial cause is Streptococcus pyogenes (15-
20%)
Presents with sore or scratchy throat
In severe bacterial cases there may be odynophagia, fever,
headache
Miscellaneous causes of pharyngitis
Primary HIV infection
Gonococcal infection
Diphtheria
Yersinia entercolitica (can have fulminant
course)
Mycoplasma pneumoniae
Chlamydia pneumoniae
A case of strep throat
Severe Acute Respiratory Syndrome (SARS)
Caused by a previously unrecognized coronavirus—genome has now
been sequenced
Clinical manifestations are similar to those of other acute
respiratory illnesses—notably, influenza
Cases in U.S. associated mainly
with travel or as secondary contacts
SARS coronavirus (SARS-CoV)
is causative of the syndrome
SARS: Radiographic findings
Early: a peripheral/pleural-based opacity
(ground-glass or consolidative) may be
the only abnormality. Look especially at
retrocardiac area
Advanced: widespread opacification
(ground-glass or consolidative) tending
to affect the lower zones and often
bilateral
Pleural effusions, lymphadenopathy, and
cavitation are not seen.
Rhinorrhea, sore throat,
mild cough, fever
Parainfluenzae and influenza
can be identified
by nasopharyngeal swab
Rapid tests are available
Treat with vaporizers,
nebulized adrenaline
Systemic or nebulized
corticosteroids in the severely sick
The steeple sign as seen on an AP neck X-ray of a child with croup
Croup
Acute Epiglottitis
A life-threatening cellulitis of the epiglottis
and adjacent structures
Onset usually sudden (as opposed to
gradual onset of croup); drooling,
dysphagia, sore throat
H. influenzae the usual pathogen both in
children (the usual patients) and adults
Acute suppurative parotitis
Uncommon, but high morbidity and
mortality
Usually associated with some combination of
dehydration, old age, malnutrition, and/or
postoperative state
S. aureus the usual pathogen
Otitis externa
Acute, localized: often S. aureus, S.
epidermidis or S. pyogenes
Acute diffuse (swimmer’s ear):
gram-negative rods, especially Ps.
Aeruginosa ; Rx: topical quinolones
Chronic: mainly with chronic otitis
media
Malignant: life-threatening infection
in diabetics, elderly,
immunecompromised
Malignant otitis externa
Diabetes mellitus
Pseudomonas
aeruginosa
Osteomyelitis of the
temporal bone
Involvement of vital
structures at base of
brain
Acute otitis media
S. pneumoniae and H. influenzae the leading causes in all
age groups (most H. flu is from non-typable strains and
not “B”)
Moraxella catarrhalis: 10% of cases
Some cases may be viral (RSV, influenza, enteroviruses)
Mycoplasma pneumoniae: inflammation of the tympanic
membrane (“bullous myringitis”)
Acute otitis media
Critical role of eustachian
tube as conduit between
nasopharynx, middle ear,
and mastoid air cells
Children have shorter,
wider eustachian tubes
than adults
Diagnosis and treatment
Presence of fluid in the middle ear AND
Ear pain, drainage, hearing loss
The fluid may take weeks to resolve
Amoxicillin remains the drug of choice
Beta-lactamase producing strains of H. influenza will need
amoxicillin/clavulanic acid or cephalosporins
Otitis Media
Vesicular lesions
Herpangina
Uncommon
Due to coxsackieviruss
Small, 1-2 mm vesicles on the soft palate, uvula, and anterior
tonsillar pillars which rupture to form small white ulcers
Occurs mainly in children
Also think of Herpes simplex virus when you see vesicular
lesions
Dr. Carlo Urbani (1956-2003)
2/28/03: Recognized
SARS while examining a
patient in Hanoi.
Identified outbreak and
raises the alarm.
Stayed caring patients
despite multiple
illnesses in staff—sent
wife and three children
back to Italy
3/29/03: Died of SARS