Upper Respiratory Tract Infections Divya Ahuja, M.D.


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  • 70% have fluid at 2 weeks
  • Upper Respiratory Tract Infections Divya Ahuja, M.D.

    1. 1. Upper Respiratory Tract InfectionsUpper Respiratory Tract Infections Divya Ahuja, M.D. November 2009
    2. 2. Burden of URIBurden of URI  Significant morbidity and direct health care costs  Direct costs of $ 17 billion annually  Occasionally leads to fatal illness  Excessive use of antibiotics a major issue
    3. 3. The Common ColdThe Common Cold Children average 8 per year, adults 3 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
    4. 4. Common ColdCommon Cold 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
    5. 5. The common coldThe common cold
    6. 6. Transmission of rhinovirusesTransmission of rhinoviruses Direct contact is the most efficient means of transmission: 40% to 90% recovery from hands. Infectious droplet nuclei Brief exposure (e.g., handshake) transmits in less than 10% of instances Kissing does not seem to be a common mode of transmission.
    7. 7. Clinical characteristicsClinical 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
    8. 8. Diagnosis and treatmentDiagnosis and treatment Main challenge is to distinguish between uncomplicated cold and streptococcal pharyngitis or bacterial sinusitis – Good examination 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
    9. 9. Acute bacterial sinusitisAcute bacterial sinusitis Epidemiological studies suggest 1 billion cases of viral rhinosinusitis occur annually in the US Of these0.5-2% are complicated by bacterial sinusitis Viral infection--> obstruction of ducts and compromise of mucocilary blanket--> acute infection from virulent organisms (most often S. pneumoniae and H. influenzae)--> opportunistic pathogens Nose blowing generates high intranasal pressures that deposit bacteria into the sinus cavity More common in adults than in children
    10. 10. Paranasal sinusesParanasal sinuses
    11. 11. Waters view (left); Coronal CTWaters view (left); Coronal CT
    12. 12. SinusitisSinusitis 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
    13. 13. Clinical featuresClinical features Clinical features – Sneezing – Nasal discharge – Facial pressure – Fever – Purulent drainage – Headache Sinus imaging not routinely recommended
    14. 14. Acute sinusitis: complicationsAcute sinusitis: complications Maxillary: usually uncomplicated Ethmoid: cavernous sinus thrombosis-serious Frontal: osteomyelitis of frontal bone; cavernous sinus thrombosis; epidural, subdural, or intracerebral abscess; orbital extension Sphenoid: Rare; extension to internal carotid artery, cavernous sinuses, pituitary, optic nerves; common misdiagnoses include ophthalmic migraine, aseptic meningitis, trigeminal neuralgia, cavernous sinus thrombosis
    15. 15. CaseCase BR 59 year old white female Diplopia and left temporal headache Thought to have temporal arteritis Started on Prednisone 100mg once daily Two months later developed cranial N palsies, headaches
    16. 16. Chronic sinusitisChronic sinusitis  The previous patient had an invasive aspergillus sinusitis as a result of chronic high dose steroid therapy, resulting in occlusion of carotid artery and invasion into the brain. She died in a month.  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;
    17. 17. Spectrum of fungal sinusitisSpectrum of fungal sinusitis  Simple colonization  Sinus mycetoma (fungus ball)  Allergic fungal sinusitis  Acute (fulminant) invasive sinusitis (notably, rhinocerebral mucormycosis)  Chronic invasive fungal sinusitis
    18. 18. Otitis externaOtitis 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
    19. 19. Malignant otitis externaMalignant otitis externa  Diabetes mellitus  Pseudomonas aeruginosa  Osteomyelitis of the temporal bone  Involvement of vital structures at base of brain
    20. 20. Acute otitis mediaAcute 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”)
    21. 21. Acute otitis mediaAcute 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
    22. 22. Diagnosis and treatmentDiagnosis 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
    23. 23. Otitis Media
    24. 24. Acute pharyngitisAcute 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
    25. 25. Acute pharyngitis: physical examAcute pharyngitis: physical exam Viral: edema and hyperemia of tonsils and pharyngeal mucosa Streptococcal: exudate and hemorrhage involving tonsils and pharyngeal walls Epstein-Barr virus (infectious mono): may also cause exudate, with nasopharyngeal lymphoid hyperplasia
    26. 26. Pharyngoconjuntival feverPharyngoconjuntival fever Adenoviral pharyngitis Pharyngeal erythema and exudate may mimic streptococcal pharyngitis Conjunctivitis (follicular) present in 1/3 to 1/2 of cases; commonly unilateral but bilateral in 1/4 of cases
    27. 27. Vesicular lesionsVesicular 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
    28. 28. Vincent’s angina and QuinsyVincent’s angina and Quinsy Vincent’s angina: anaerobic pharyngitis (exudate; foul odor to breath) Ludwig’s angina- cellulitis of dental origin Quinsy: peritonsillitis/peritonsillar abscess. Medial displacement of the tonsil; often spread of infection to carotid sheath
    29. 29. Diphtheria fibrous pseudomembrane with necrotic epithelium and leukocytes
    30. 30. DiphtheriaDiphtheria Classic diphtheria (Corynebacterium diphtheriae): slow onset, then marked toxicity Arcanobacterium hemolyticum (formerly Cornyebacterium hemolyticum): exudative pharyngitis in adolescents and young adults with diffuse, sometimes pruritic maculopapular rash on trunk and extremities
    31. 31. Miscellaneous causes of pharyngitisMiscellaneous causes of pharyngitis Primary HIV infection Gonococcal infection Diphtheria Yersinia entercolitica (can have fulminant course) Mycoplasma pneumoniae Chlamydia pneumoniae
    32. 32. TreatmentTreatment Symptomatic Penicillin for Strep throat Macrolides for pen allergic patients Add an anti-anaerobic agent for Vincent’s and Ludwig’s angina
    33. 33. Acute laryngotracheobronchitis (croup)Acute laryngotracheobronchitis (croup) Children, most often in 2nd year Parainfluenza virus type 1 most often in U.S.A. but other agents are Mycoplasma pneumoniae, H. influenza Involvement of larynx and trachea: stridor, hoarseness, cough Subglottic involvement: high-pitched vibratory sounds Can lead to respiratory failure (2% get hospitalized)
    34. 34. CroupCroup 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
    35. 35. Acute epiglottitisAcute 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
    36. 36. Acute suppurativeAcute suppurative parotitisparotitis 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
    37. 37. Deep fascial space infections ofDeep fascial space infections of the head and neckthe head and neck Several syndromes according to anatomic planes Can complicate odontogenic or oropharyngeal infection Ludwig’s angina: bilateral involvement of submandibular and sublingual spaces (brawny cellulitis at floor of mouth)
    38. 38. Deep fascial space infections ofDeep fascial space infections of the head and neck (2)the head and neck (2) Lemierre syndrome: suppurative thrombophlebitis of internal jugular vein (Fusobacterium necrophorum) Retropharyngeal space infection: contiguous spread from lateral pharyngeal space or infected retropharyngeal lymph node; complications include rupture into airway, septic thrombosis of internal jugular vein
    39. 39. Lemierre’s syndrome
    40. 40. Severe acute respiratorySevere acute respiratory distress syndrome (SARS)distress 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
    41. 41. SARS: Radiographic findingsSARS: 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.
    42. 42. Dr. Carlo Urbani (1956-2003)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