1. Upper Respiratory Tract Infections Méhes Leonóra, MD Department of Infectious and Pediatric Immunology 2012.11.06

2. UR T I the most common acute illness in the outpatient setting common cold: mild, self-limited, catarrhal syndrome of the nasopharynx life-threatening illness: epiglottitis viruses, bacteria primary infection or superinfection sinuses, nasal passages, pharynx, and larynx rhinitis, pharyngitis, sinusitis, epiglottitis, laryngitis, and tracheitis

3. Pathophysiology direct invasion of the mucosa person-to-person spread of viruses Inoculation: secretions are transferred by touching a hand exposed to pathogens to the nose or mouth directly inhaling respiratory droplets from an infected person Barriers: physical, humoral, and cellular immune defenses

4. Adenoids and tonsils: immune cells Humoral immunity: immunoglobulin A cellular immunity : resident and recruited macrophages, monocytes, neutrophils, and eosinophils Normal nasopharyngeal flora, including various staphylococcal and streptococcal species increased risk for contracting a URTI, increased risk for a severe or prolonged course of disease

5. - Viral agents: a vast number of serotypes, which undergo frequent changes in antigenicity Incubation times: Rhinoviruses and group A streptococci: 1-5 days influenza and parainfluenza: 1-4 days RSV: a week Pertussis: 7-21days Diphtheria: 1-10 days EBV: 4-6 weeks

6. Symptoms local swelling, erythema, edema, secretions, and fever inflammatory narrowing at the level of the epiglottis and larynx may result in a dangerous compromise of airflow, especially in children

7. Epidemiology Nasopharyngitis High incidence in children < 5 y Pharyngitis 1% of all ambulatory office visits Highest incidebce in children aged 4-7 y Rhinosinusitis > 80% of patients with uncomplicated viral URIs bacterial rhinosinusitis 2% of persons with viral URIs

8. Epidemiology Epiglottitis 6-14/100,000 children aged 2-7 y, peak incidence: 3 y dramatically decrease since the introduction of the Haemophilus influenzae type B (Hib) vaccine Laryngitis and laryngotracheitis people of any age, children 6 mo - 6 y, peak incidence: 2 y dramatically reduced rates of pertussis

9. Group A streptococci: 5-15% of all pharyngitis, rarely in children < 2 y EBV infection: childhood: indistinguishable from other infections 35-50% of adolescents and young adults who contract EBV infection have mononucleosis diphtheria vaccine: dramatically decreased

10. Viral nasopharyngitis 2-3 days after inoculation last 6-8 days in children 1-2 y, in adults 3-14 days > 2 w: alternative diagnoses (allergy, sinusitis, pneumonia) Nasal symptoms: rhinorrhea, congestion or obstruction of nasal breathing, sneezing significant rhinorrhea is more characteristic of a viral infection rather than a bacterial infection Pharyngeal symptoms: sore throat, odynophagia, dysphagia. sensation of a lump when swallowing Cough: laryngeal involvement, related to nasal secretions

11. Hyposmia Headache Sinus symptoms: congestion or pressure Photophobia or conjunctivitis: adenoviral inf Fever: 39.4°C, influenza infection: 40°C Gastrointestinal symptoms: nausea, vomiting, diarrhea - children Severe myalgia: influenza inf Fatigue or malaise

12. Bacterial pharyngitis symptoms persist or progressively worsen after the first 5-7 days group A streptococci: fever, the absence of cough, rhinorrhea, and conjunctivitis, patient age of 5-15 years Pharyngeal symptoms: sudden sore throat, odynophagia, dysphagia Secretions: thick or yellow

13. Rash: in children or adolescents Abdominal pain: streptococcal disease, influenza Cough Headache: group A streptococci, mycoplasma inf Fatigue or malaise Fever: 38.9°C in infants and young children

14. Epiglottitis children aged 1-5 years sudden onset of symptoms: Sore throat odynophagia or dysphagia globus sensation of a lump in the throat dysphonia or loss of voice Dry cough or no cough, dyspnea Fever, fatigue or malaise

15. Physical signs Pharyngeal erythema – adenovirus, group A streptococci: palatal petechiae Exudates: adenovirus, EBV, bacteria (white-yellow patches) Mucosal ulcers, erosions: HSV, coxsackie virus (herpangina), enterovirus, primary HIV Tonsillar hypertrophy Anterior cervical lymphadenopathy: EBV, HIV, streptococci Conjunctivitis: adenovirus Fever: EBV, influenza Exanthem: group A streptococcal infections, scarlet fever

16. Mononucleosis infectiosa - Tonsillopharyngitis, cervical lymphadenitis - CBC: leucocytosis, activated lymphocytes, ESR, CRP, liver enzimes throat swab culture - Hepato-, splenomegaly - Difficulty of swallowing, extremly enlarged lymph nodes on the neck - EBV (CMV) - Th: symptomatic, rarely steroid + ab (clindamycin) - Ampicillin rash: 8-10 d after adminis- tration of an amoxicillin derivative ab, not an allergic reaction

17. Causes Nasopharyngitis: rhino-, corona-, entero-, orthomyxo-, paramyxoviruses, RSV, EBV Pharyngitis: adenovirus, influenza, coxsackie, HSV, EBV, CMV, Gr A, C, G streptococci, corynebacterium, M. pneumoniae, C. pneumoniae Rhinosinusitis: rhino-, corona-, adeno-, entero-, influenza, RSV, S.pneumoniae, H. influenzae, M. catarrhalis, Gr A strepto; nosocomial: MRSA, E.coli, P. aeruginosa, Aspergillus Epiglottitis: (Hib), Gr A strepto, S. pneumoniae, M. catarrhalis Laryngotracheitis: parainfluenza, influenza, RSV

18. Diagnosis Rapid antigen test for gr A strepto Cultures (throat swab) Antistreptolysin O: peak: 4-5 w, no dg value in acut pharyngitis Sinus puncture Rapid test for influenza (nasopharyngeal swab) 70% sensitive, 90% specific EBV: heterophile antibody test CBC, ESR Blood culture X-ray, CT scan

19. Treatment Self-limited viral infections Immunocompromised p: acyclovir ( HSV), gancyclovir (CMV) Strepto: amoxi, cefurox, pen G, amoxi/clav, ceftriax, azithro Pertussis: clarithro, azithro Epiglottitis: cefurox, ceftriax, cefotax Laryngotracheitis: - O2 - Steroids - Antibiotics: pertussis - Sedatives - Inhaled epinephrine

20. Acut otitis media - AOM Infancy, early childhood freqvent < 2 y Virus, bact: S.pneumoniae, H.influenzae, M. catarrhalis, S. pyogenes Clinical signs: fever, vomiting, irritability, earache, tragus tenderness Otoscopic picture: tympanic membrane inflammed, convexity Complications: acut mastoiditis, meningitis

21. Treatment PC not necessary Otitis media serosa: no PC, ab Th: I. choice: amoxicillin, amoxi/clav 2. gen cephsp: cefprozil, cefuroxim, 3.gen cephsp: cefixim, ceftriaxon penicillin allergy: macrolid