Upper Respiratory Tract Infection_ Practice Essentials, Background, Pathophysiology

8/16/2019 Upper Respiratory Tract Infection_ Practice Essentials, Background, Pathophysiology

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5/27/2016 Upper Respiratory Tract Infection: Practice Essentials, Background, Pathophysiology

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Drooling, difficulty or pain during swallowing, globus sensation of a lump in

the throatMuffled dysphonia or loss of voiceDry cough or no cough, dyspnea

Fever, fatigue or malaise (may be seen with any URI)Tripod or sniffing posture

Laryngotracheitis and laryngotracheobronchitis

Nasopharyngitis often precedes laryngitis and tracheitis by several days

Swallowing may be difficult or painfulPatients may experience a globus sensation of a lump in the throat

Hoarseness or loss of voice is a key manifestation of laryngeal involvement

Features of whooping cough (pertussis) are as follows:

The classic whoop sound [4] is an inspiratory gasping squeak that rises inpitch, typically interspersed between hacking coughs

The whoop is more common in childrenCoughing often comes in paroxysms of a dozen coughs or more at a time

and is often worst at night

The 3 classic phases of whooping cough are as follows:

Catarrhal (7-10 days) with predominantly URI symptomsParoxysmal (1-6 weeks) with episodic cough

Convalescent (7-10 days) of gradual recovery [5]

See Clinical Presentation for more detail.

Diagnosis

Tests of nasopharyngeal specimens for specific pathogens are helpful when

argeted therapy depends on the results (eg, group A streptococcal infection,gonococcus, pertussis). Specific bacterial or viral testing is also warranted in other

selected situations, such as when patients are immunocompromised, during certainoutbreaks, or to provide specific therapy to contacts.

Diagnosis of specific disorders is based on the following:

Group A streptococcal infection: Clinical findings or a history of exposure to acase, supported by results of rapid-detection assays and cultures (positive

rapid antigen detection tests do not necessitate a backup culture) Acute bacterial rhinosinusitis: Laboratory studies are generally not indicated;

Computed tomography (CT) scanning or other sinus imaging may beappropriate if symptoms persist despite therapy or if complications (eg,extension of disease into surrounding tissue) are suspected

Influenza: Rapid tests have over 70% sensitivity and more than 90%specificity

Mononucleosis: Heterophile antibody testing (eg, Monospot)Herpes simplex virus infection: Cell culture or polymerase chain reaction

(PCR) assayPertussis: Rapid tests; culture of a nasopharyngeal aspirate (criterionstandard)

Epiglottitis: Direct visualization by laryngoscopy, performed by anotorhinolaryngologist

Gonococcal pharyngitis: Throat culture for Neisseria gonorrhoeae

Blood cultures are typically appropriate only in hospitalized patients with suspected

systemic illness. Imaging studies are warranted in patients with suspected masslesions (eg, peritonsillar abscess, intracranial suppurative lesions).

See Workup for more detail.

Management

Symptom-basedtherapy represents the mainstay of URI treatment inimmunocompetent adults. Antimicrobial or antiviral therapy is appropriate inselected patients.

Epiglottitis

Immediately admit the patient to the nearest hospital

Avoid i nstrumentation; insertion of tongue depressors or other instrumentsmay provoke airway spasm and precipitate respiratory compromiseMonitor for respiratory fatigue, visually and with continuous pulse oximetry

Administer oxygen according to pulse oximetry resultsHave equipment and personnel available for immediate intubation if

necessaryStart intravenous (IV) antibiotics after collecting culture specimens

Empiric coverage for Haemophilus influenzae is appropriate; commonchoices include ceftriaxone or other third-generation cephalosporins,cefuroxime, and cefamandole

Correct volume deficits with IV fluids; avoid sedatives

Laryngotracheitis

Hospitalization may be necessary, especially in infants and young children

who have hypoxemia, volume depletion, a risk of airway compromise, or respiratory f atigueMild cases of croup (ie, laryngotracheobronchitis) may be managed at home

with moist air inhalationHospitalized patients require monitoring for respiratory fatigue, visually and

with continuous pulse oximetryExpertise for immediate intubation and access to the necessary equipmentare required if respiratory failure is a possibility

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A host of inflammatory cytokines mediates the immune response to invading

pathogens. Normal nasopharyngeal flora, including various staphylococcal andstreptococcal species, help to defend against potential pathogens. Patients withsuboptimal humoral and phagocytic immune function are at increased risk for

contracting a URI, and they are at increased risk for a severe or prolonged course of disease.

Inflammation (chronic or acute) from allergy predisposes to URI. Children withallergy are particularly subject to frequent URIs.

Infection

Person-to-person spread of viruses accounts for most URIs. Household and childcare settings can serve as reservoirs for infection. Bacterial infections may develop

de novo or as a superinfection of a viral URI.

Viral agents occurring in URIs include a vast number of serotypes, which undergo

frequent changes in antigenicity, posing challenges to immune defense. Pathogensresist destruction by a variety of mechanisms, including the production of toxins,proteases, and bacterial adherence factors, as well as the formation of capsules

hat resist phagocytosis.

Incubation times before the appearance of symptoms vary among pathogens.

Rhinoviruses and group A streptococci may incubate for 1-5 days, influenza andparainfluenza may incubate for 1-4 days, and respiratory syncytial virus (RSV) mayincubate for a week. Pertussis typically incubates for 7-10 days, or even as long as

21 days, before causing symptoms. Diphtheria incubates for 1-10 days. Theincubation period of Epstein-Barr virus (EBV) is 4-6 weeks.

Most symptoms of URIs—including local swelling, erythema, edema, secretions,and fever—result from the inflammatory response of the immune system to

invading pathogens and from toxins produced by pathogens.

An initial nasopharyngeal inf ection m ay spread to adjacent structures, resulting inhe following:

SinusitisOtitis media

EpiglottitisLaryngitis

TracheobronchitisPneumonia

Inflammatory narrowing at the level of the epiglottis and larynx may result in adangerous compromise of airflow, especially in children, in whom a small reductionin the luminal diameter of the subglottic larynx and trachea may be critical. Beyond

childhood, laryngotracheal inflammation may also pose serious threats to individualswith congenital or acquired subglottic stenosis.

Susceptibility

Genetic susceptibility is involved in determining which patients have more severe

disease courses than others. There are some recognized candidate genepolymorphisms with known functional changes in genes that may lead to

immunosuppression. [8] It has also been shown that host immunogenetic variationplays a role in the immune response to H1N1 and H5N1 viruses, thereby influencing

disease severity and outcome in influenza caused by these viruses. [9, 10]

Etiology

Most URIs are viral in origin. Typical viral agents that cause URIs include thefollowing:

RhinovirusesCoronaviruses

AdenovirusesCoxsackieviruses

For the most part, similar agents cause URI in adults and children; however,Moraxella catarrhalis and bocavirus cause URIs more commonly in children than inadults.

Nasopharyngitis

Of the more than 200 viruses known to cause the symptoms of the common cold,he principal ones are as follows:

Rhinoviruses: These cause approximately 30-50% of colds in adults; they

grow optimally at temperatures near 32.8°C (91°F), which is the temperatureinside the human nares

Coronaviruses: While they are a significant cause of colds, exact casenumbers are difficult to determine because, unlike rhinoviruses,coronaviruses are difficult to culture in the laboratory

Enteroviruses, including coxsackieviruses, echoviruses, and others

Other viruses that account for many URIs include the following:

Adenoviruses

Orthomyxoviruses (including influenza A and B viruses)Paramyxoviruses (eg, parainfluenza virus [PIV])RSV

EBVHuman metapneumovirus (hMPV)

Bocavirus: Commonly associated with nasopharyngeal symptoms in children[11]





Unidentified, but presumably viral, pathogens account for more than 30% of

common colds in adults. In addition, varicella, rubella, and rubeola infections maymanifest as nasopharyngitis before other classic signs and symptoms develop.

Pharyngitis

This is most often viral in origin. Recognition of group A streptococcal pharyngitis is

vital because serious complications may follow untreated disease.

Viral causes of pharyngitis include the following:

Adenovirus: May also cause laryngitis and conjunctivitis

Influenza virusesCoxsackievirus

Herpes simplex virus (HSV)EBV (infectious mononucleosis)

Cytomegalovirus (CMV)

Bacterial causes of pharyngitis include the following:

Group A streptococci (approximately 5-15% of all cases of pharyngitis in

adults; 20-30% in children) [2]

Group C and G streptococciNeisseria gonorrhoeae

Arcanobacterium ( Corynebacterium) hemolyticumCorynebacterium diphtheriae

Atypical bacteria (eg, Mycoplasma pneumoniae and Chlamydia pneumoniae;

absent lower respiratory tract disease, the clinical significance of thesepathogens is uncertain)

Anaerobic bacteria

Rhinosinusitis

Rhinosinusitis in an immunocompetent person is typically related to anuncomplicated viral URI. Viral causes are similar to those of viral nasopharyngitis

and include the following:

Rhinovirus

EnterovirusCoronavirusInfluenza A and B virus

PIVRSV

Adenovirus

Bacterial causes are similar to those seen in otitis media. Bacterial pathogens

isolated from maxillary sinus aspirates of patients with acute bacterial rhinosinusitis

include the following[7] :

Streptococcus pneumoniae: 38% in adults, 21-33% in childrenHaemophilus infl uenzae: 36% in adults, 31-32% in children

Moraxella catarrhalis: 16% in adults; 8-11% in childrenStaphylococcus aureus: 13% in adults, 1% in children

Other pathogens include group A streptococci and other streptococcal species.Uncommon causes include C pneumoniae, Neisseria species, anaerobes, and gram-negative rods.

Nosocomial sinusitis often involves pathogens that colonize the upper respiratoryract and migrate into the sinuses. Prolonged endotracheal intubation places

patients at increased risk for nosocomial sinusitis. Methicillin-resistant S aureus

(MRSA) is less common than sensitive staphylococci.[7] Gram-negative bacilli (eg,

Escherichia coli,Pseudomonas aeruginosa) are other causes.

Aspergillus species are the leading causes of noninvasive fungal sinusitis. Although

fungi are part of the normal flora of the upper airways, they may cause acutesinusitis in patients with immunocompromise or diabetes mellitus.

Epiglottitis

This is a bacterial infection. In the vast majority of children, H influenzae type b

(Hib) is isolated from blood or epiglottal cultures. Since the routine use of the Hibconjugate vaccine began in 1990, case rates in children younger than 5 years havedeclined by more than 95%. The prevalence of invasive Hib disease is

approximately 1.3 cases per 100,000 children.[12] Rates in adults have remained low

and stable; Alaskan Natives have the highest rates of disease.

Other bacteria, found more commonly in adults than in children, include group Astreptococci, S pneumoniae, and M catarrhalis. In adults, cultures are most likely to

be negative.

Laryngotracheitis

Croup, or laryngotracheobronchitis, is typically caused by PIV type 1, 2, or 3. PIVsaccount for up to 80% of croup cases. PIV type 1 is the leading cause of croup in

children. [13] Other viruses include influenza viruses and RSV. Uncommon causesinclude hMPV, adenovirus, rhinovirus, enterovirus (including coxsackievirus and

enteric cytopathic human orphan [ECHO] viruses), and measles virus.

Approximately 95% of all cases of whooping cough are caused by the gram-

negative rod Bordetella pertussis. The remaining cases result from B parapertussis.

Other forms of laryngitis and laryngotracheitis are typically caused by viruses similar o those that cause nasopharyngitis, including rhinovirus, coronavirus, adenovirus,

influenza virus, parainfluenza virus, and RSV. Candida species may cause laryngitisin immunocompromised hosts.





Bacterial laryngitis is far less common than viral laryngitis. [14] Bacterial causesinclude the following:Group A streptococci

Corynebacterium diphtheriae, an aerobic gram-positive rod that may infect

only the larynx or may represent an extension of nasopharyngeal infectionChlamydia pneumoniae

Mycoplasma pneumoniaeMoraxella catarrhalis

H influenzaeS aureus

Mycobacterium tuberculosis: Tuberculosis has been reported in renal

transplant recipients and human immunodeficiency virus (HIV) infectedpatients

Risk factors for URIs

Risk factors for contracting a URI include the following:

Contact: Close contact with small children who frequent group settings, suchas school or daycare, increases the risk of URI, as does the presence of URI

in the household or familyInflammation: Inflammation and obstruction from allergic rhinitis or asthmacan predispose to infections

Travel: The incidence of contracting a URI is increased because of exposureto large numbers of individuals in closed settings

Smoking and exposure to second-hand smoke: These may alter mucosalresistance to URI

Immunocompromise that affects cellular or humoral immunity: Weakenedimmune function may result from splenectomy, HIV infection, use of corticosteroids, immunosuppressive treatment after stem cell or organ

transplantation, multiple medical problems, or common stress; ciliadyskinesia syndrome and cystic fibrosis also predispose individuals to URIs

Anatomic changes due to facial dysmorphisms, previous upper airwaytrauma, and nasal polyposis

Carrier state: Although some people are chronic carriers of group A

streptococci, repeated URIs in such patients may be viral in origin [2]

Epidemiology

URIs are the most common infectious illness in the general population and are theleading cause of missed days at work or school. They represent the most frequent

acute diagnosis in the office setting.[15]

Nasopharyngitis

The incidence of the common cold varies by age. Rates are highest in childrenyounger than 5 years. Children who attend school or day care are a large reservoir

for URIs, and they transfer infection to the adults who care for them. In the firstyear after starting at a new school or day care, children experience more infections,

as do their family members. Children have about 3-8 viral respiratory illnesses per year, adolescents and adults have approximately 2-4 colds annually, and peopleolder than 60 years have fewer than 1 cold per year.

Pharyngitis

Acute pharyngitis accounts f or 1% of all ambulatory office visits.[15] The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 years.

Rhinosinusitis

Sinusitis is common in persons with viral URIs. Transient changes in the paranasal

sinuses are noted on computed tomography (CT) scans in more than 80% of

patients with uncomplicated viral URIs. [16] However, bacterial rhinosinusitis occurs

as a complication in only about 2% of persons with viral URIs. [17]

Epiglottitis

The occurrence of epiglottitis has decreased dramatically in the United States and

other developed nations since the introduction of Hib vaccine. A Swedish studydocumented that the Hib vaccination program was associated with a decrease in theoverall annual incidence of acute epiglottitis from 4.5 cases to 0.98 cases per

100,000 population; the incidence decreased in children and adults. However, theannual incidence of pneumococcal epiglottitis in adults increased from 0.1 to 0.28

cases per 100,000 population over the same period. [18]

Laryngitis and laryngotracheitis

Croup, or laryngotracheobronchitis, may affect people of any age but usually occursin children aged 6 months to 6 years. The peak incidence is in the second year of

life. Thereafter, the enlarging caliber of the airway reduces the severity of themanifestations of subglottic inflammation.

Vaccination has dramatically reduced rates of pertussis. However, the incidence of whooping cough in the United States has increased steadily since 2007, reaching

approximately 9 cases per 100,000 population in 2010. Rates of pertussis arehighest in infants below age 1 year; adolescents and adults accounted for approximately 44% of the 27,550 cases of pertussis reported in the United States in

2010.[19]

orldwide, pertussis has an estimated incidence of 48.5 million cases and causesnearly 295,000 deaths per year. In low-income countries, the case-fatality rate

among infants may be as high as 4%. [20]





Although pertussis is a nationally notif iable disease in the United States, many

cases likely go undiagnosed and unreported. On the other hand, challenges inlaboratory diagnosis and overreliance on polymerase chain reaction (PCR) assayshave resulted in reports of respiratory illness outbreaks mistakenly attributed to

pertussis.[21]

Occurrence rate of selected pathogens

Group A streptococcal bacteria cause approximately 5-15% of all pharyngitis

infections,[2] accounting for several million cases of streptococcal pharyngitis eachyear. This infection is rarely diagnosed in children younger than 2 years.

Influenza affects approximately 5-20% of the US population during each flu season.[22] Early presentations include symptoms of URI.

EBV infection affects as many as 95% of American adults by age 35-40 years.Childhood EBV infection is indistinguishable from other transient childhood

infections. Approximately 35-50% of adolescents and young adults who contract

EBV infection have mononucleosis.[23]

Diphtheria rates fell dramatically in the United States after the advent of diphtheriavaccine. Since 1980, the prevalence of diphtheria has been approximately 0.001

case per 100,000 population. A confirmed case of the disease has not been

reported in the United States since 2003.[24] However, diphtheria remains endemicin developing countries.

Seasonality

Although URIs m ay occur year round, in the United States most colds occur duringfall and winter. Beginning in late August or early September, rates of colds increase

over several weeks and remain elevated until March or April. [25] Epidemics and

mini-epidemics are most common during cold months, with a peak incidence fromlate winter to early spring.

Cold weather results in more time spent indoors (eg, at work, home, school) and

close exposure to others who may be infected. Humidity may also affect theprevalence of colds, because most viral URI agents thrive in the low humidity that is

characteristic of winter months. Low indoor air moisture may increase friability of thenasal mucosa, increasing a person's susceptibility to infection.

Laryngotracheobronchitis, or croup, occurs in fall and winter. Seasonality does notaffect rates of epiglottitis.

The figure below illustrates the peak incidences of various agents by season.

Rhinoviruses, which account for a substantial percentage of URIs, are most active inspring, summer, and early autumn. Coronaviral URIs manifest primarily in the winter

and early spring. Enteroviral URIs are most noticeable in summer and early fall,when other URI pathogens are at a nadir. Adenoviral respiratory infections canoccur throughout the year but are most common in the late winter, spring, and early

summer.

Seasonal variation of selected upper respiratory tract infection pathogens. PIV is parainfluenzavirus, RSV is respiratory syncytial virus, MPV is metapneumovirus, and Group A Strept isgroup A streptococcal disease.

Seasonal influenza typically lasts from November until March. Some PIVs have abiennial pattern. The patterns for human PIV types 1-3 are as follows:

Human PIV type 1: Currently produces autumnal outbreaks in the UnitedStates during odd-numbered years; the leading cause of croup in children

Human PIV type 2: May cause annual or biennial fall outbreaksHuman PIV type 3: Peak activity is during the spring and early summer

months; however, the virus may be isolated throughout the year. [13]

Human metapneumovirus (hMPV) infection may also occur year round, although the

infection rates peak between December and February.

Race- and sex-related demographics

No notable racial difference is observed with URIs. However, Alaskan Natives have

rates of Hib disease higher than those of other groups. [12]

Sexual disparities among URIs are as follows:

Rhinitis: Hormonal changes during the middle of the menstrual cycle and

during pregnancy may produce hyperemia of the nasal and sinus mucosaand increase nasal secretions; URI may be superimposed over these

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baseline changes and may increase the intensity of symptoms in somewomenNasopharyngitis: The common cold occurs frequently in women, especially

those aged 20-30 years [25] ; this frequency may represent increasedexposure to small children, who represent a large reservoir for URIs, but

hormonal effects on the nasal mucosa may also play a roleEpiglottitis: A male predominance is reported, with a male-to-female ratio of

approximately 3:2Laryngotracheobronchitis, or croup: More common in boys than in girls, witha male-to-female ratio of approximately 3:2

Age-related demographics

The incidence of the common cold varies by age. Rates are highest in children

younger than 5 years. Children have approximately 3-8 viral respiratory illnesses per year, while adolescents and adults have approximately 2-4 colds a year, and people

older than 60 years have fewer than 1 cold per year.

The age-related occurrence of other infections is as follows:

Viral and bacterial pharyngitis: Peaks in children aged 4-7 years.Epiglottitis: Typically occurs in children aged 2-7 years and has a peakincidence in those aged 3 years

Laryngotracheobronchitis (croup): As previously stated, it may affect peopleof any age but usually occurs in children aged 6 months to 6 years; the peak

incidence is in the second year of life

Prognosis

URIs cause people to spend time away from their usual daily activities, but alone,hese infections rarely cause permanent sequelae or death. URIs may, however,

serve as a gateway to infection of adjacent structures, resulting in the followinginfections (and others, as well):

Otitis mediaBronchitisBronchiolitis

PneumoniaSepsis

MeningitisIntracranial abscess

Serious complications may result in clinically significant morbidity and rare deaths.

Nasopharyngitis

A common cold may last up to 14 days, with symptoms averaging 7-11 days in

duration.[17]

Fever, sneezing, and sore throat typically resolve early, whereas cough and nasal

discharge are among the symptoms that last longest.

Att endance at day care m ay affect the duration of symptoms in young children. Inone study, the duration of viral URIs ranged from 6.6 days for children aged 1-2

years in home care to 8.9 days for children younger than 1 year who were in daycare. Young children in day care were also more likely to have protracted respiratory

symptoms lasting more than 15 days. [26]

Most patients with influenza recover within a week, although cough, fatigue, andmalaise may persist for up to 2 weeks. For newborns, elderly persons, and patients

with chronic medical conditions, the flu may be life threatening. More than 200,000people per year are hospitalized because of complications of the flu, with 0.36

deaths per 100,000 patients occurring annually. [27] Influenza may be followed by

bacterial superinfection.

Pharyngitis

Viral pharyngitis typically resolves in 1-2 weeks, but immunocompromised persons

may have a more severe course.

Untreated group A streptococcal pharyngitis can result in the following:

Acute rheumatic f ever Acute glomerulonephritis

Peritonsillar abscessToxic shock syndromeImpetigo

Cellulitis or abscessOtitis

SinusitisConjunctivitis

Bronchitis

Mortality from group A streptococcal pharyngitis is rare, but serious morbidity or

death may result from one of its complications.

Streptococcal pharyngitis without complications rarely poses significant risk for morbidity. However, retropharyngeal, intraorbital, or intracranial abscesses may

cause serious sequelae. The risk of mortality is significant in patients who progresso streptococcal toxic shock syndrome, which is characterized by multiorgan failure

and hypotension.

In patients with penicillin-sensitive streptococcal pharyngitis, symptomaticimprovement is expected within 24-72 hours if antibiotic treatment is started in the

first 24 hours after onset. Treatment failures are common and are mainly attributed





o poor adherence, antibiotic resistance, and untreated close contacts, usually within

he household or family.

A chronic carrier state may develop with group A streptococcal infection. Eradicatinghe pathogen is difficult in these cases; however, carriers without active symptoms

are unlikely to spread group A streptococci, and they are at low risk for developingrheumatic fever.

Mononucleosis

ith infectious mononucleosis from EBV, complete resolution of symptoms mayake up to 2 months. Acute symptoms rarely last more than 4 months. EBV

ypically remains dormant throughout the patient's life. Reactivation of the virus isnot usually symptomatic.

Rhinosinusitis

The prognosis is generally favorable for acute rhinosinusitis, and many cases appear

o resolve even without antibiotic therapy. As many as 70% of immunocompetentadults with rhinosinusitis begin to improve within 2 weeks of presentation without

antibiotics. With antibiotics, up to 85% have improvement at 2 weeks. Completeresolution may take weeks to months.

Sinusitis itself is rarely life threatening, but it can lead to serious complications if the

infection extends into surrounding deep tissue, including the following:

Orbital cellulitis

Subperiosteal abscessOrbital abscess

Frontal and maxillary osteomyelitisSubdural abscess

MeningitisBrain abscess

Epiglottitis

Epiglottitis poses a risk of death due to sudden airway obstruction and other complications, including septic arthritis, meningitis, empyema, and mediastinitis. In

adults, epiglottitis has a fatality rate of approximately 1%.

The prognosis is favorable with appropriate airway management, and most patients

noticeably improve within 24-48 hours after antibiotics are started. Rarely, cases of epiglottitis may recur. Recurrent symptoms raise concern about potential underlying

disorders, such as rheumatic conditions, sarcoidosis, and occult malignancy.

Laryngitis and laryngotracheitis

ith croup, laryngotracheobronchitis typically begins to improve within 3-4 days.

Recovery is usually complete. However, patients may have a recurrence, includingduring the same season.

Pertussis (whooping cough) leads to hospitalization in more than half of infantsyounger than 12 months and particularly in infants younger than 6 months. Infantsand young children are most susceptible to severe courses that include respiratory

compromise.

Of infants who are hospitalized with pertussis, approximately 50% have apnea, 20%

develop pneumonia, 1% have seizures, 1% die, and 0.3% have encephalopathy. [28]

Recovery from whooping cough is typically complete. However, paroxysms of

coughing may last for several weeks.

Complications

Most URIs are self-limited and resolve completely. However, a variety of conditionsmay complicate a URI. Fluid loss may occur in patients unable to tolerate adequate

oral intake because of upper airway inflammation or may result from fever. Otitis

media may complicate 5% of colds in children and up to 2% of colds in adults [29]

Airway hyperreactivity may i ncrease aft er a URI, resulting in new or exacerbated

asthma. Cough asthma, wherein a cough is the predominant manifestation of reactive airways disease, may mimic ongoing infection. This may be diagnosed withpulmonary function testing.

A postinfectious cough is defined as coughing that persists 3-8 weeks aft er t heonset of a URI in the absence of other clearly defined causes. Exacerbations of chronic obstructive pulmonary disease, including emphysema and chronic bronchitis,

may occur during and after a URI. Upper airways cough syndrome (post-nasal drip)may result from upper airway secretions dripping onto the pharynx. Epistaxis may

also occur.

Lower respiratory tract disease and sepsis represent serious complications,

especially in patients with immunocompromise. Lower respiratory tract diseaseshould be considered when symptoms such as fever, cough, sputum, and malaiseworsen progressively or after initial transient improvement. Tachypnea and dyspnea

are also signs of lower respiratory involvement.

Viral infection and resulting inflammation may make an individual susceptible to

concomitant or sequential infection with a bacterial agent. Streptococcus

pneumoniae, Staphylococcus aureus, H influenzae, and Streptococcus pyogenesare common superinfecting agents. Meningococci may cause superinfection with

influenzal infections.

Inflammation of the larynx and trachea area may lead to airway compromise,

especially in children and in patients with narrowed airways due to congenital or acquired subglottic stenosis. The work of breathing during epiglottitis or





laryngotracheitis may lead to respiratory failure. Sleep apnea may occur from

hypertrophied tonsils.

Deep tissue infection may occur by extension of the infection into the orbit, middleear, cranium, or other areas. Peritonsillar abscess (quinsy) may complicate bacterial

pharyngitis, leading to difficulty swallowing and pain radiating to the ear.Retropharyngeal abscess may also complicate pharyngitis. Lemierre syndrome is an

extension of pharyngitis that leads to a suppurative thrombophlebitis of the internalugular vein; septic thromboemboli may then spread throughout the body.

Complications of sinusitis include the following:

Orbital cellulitisSubperiosteal abscess

Orbital abscessMastoiditis

Frontal or maxillary osteomyelitisSubdural abscess

Cavernous sinus thrombosisBrain abscess

Suspect a deep tissue infection when a patient has orbital or periorbital swelling,proptosis, impaired extraocular movements, or impaired vision. Signs of increasedintracranial pressure (eg, papilledema, altered mental status, neurologic findings)

may suggest intracranial involvement.

Encephalitis, meningitis, or subarachnoid hemorrhage may follow a URI.

Osteomyelitis may complicate persistent or recurrent sinusitis. Osteomyelitis mayaffect the orbital plate, frontal bone, or sphenoid bone. Mucoceles are expanding

cystic defects of the paranasal sinuses that may result from prolonged sinusitis.Epiglottic abscess may result from epiglottitis.

Lymphadenitis may follow or accompany URI. Guillain-Barré syndrome may

manifest as an ascending polyneuropathy a few days or weeks after a URI. Inchildren or adolescents, the use of aspirin during a viral infection may rarely cause

Reye syndrome. Aspirin is contraindicated for the management of fevers in childrenor adolescents.

URI, especially with fever, may increase the work of the heart, adding strain to

persons with suboptimal cardiovascular status, and can lead to cardiovascular decompensation. Myositis or pericarditis may result from viral infection.

Hyperglycemia may occur during a URI in patients with diabetes. Rib fracture maybe seen following an episode of severe coughing, such as that associated withwhooping cough. Hernia may develop following an episode of severe coughing.

Cutaneous complications such as rash, cellulitis, and toxic shock syndrome mayoccur with group A streptococcus. This pathogen can also be associated with

glomerulonephritis, acute rheumatic fever, and PANDAS syndrome (Pediatric Autoimm une Neuropsychiatric Disorders Associated with Streptococcal infections).

Hemoptysis suggests the possibility of tuberculosis. A tuberculin skin test, chest

radiography, or both are appropriate in these patients.

Complications of specific conditions

Complications of group A streptococcal disease

Group A streptococcal pharyngitis is of special concern because its complications

include streptococcal toxic shock syndrome, acute rheumatic fever (ARF), acuteglomerulonephritis, and scarlet fever, as well as cutaneous infections. In addition,his pathogen is readily transmissible, especially in households, families, and other

intimate groups.

ARF affects approximately 3% of patients wit h strep throat, primarily occurring in

persons aged 6-20 years. The condition develops approximately 2-4 weeks after streptococcal pharyngitis occurs, and it may last several months. Signs of rheumatic

fever include arthritis, fever, and valvular disease. Uncommon features include anexpanding truncal exanthem (erythema marginata), subcutaneous nodules, andchorea.

Poststreptococcal glomerulonephritis can affect persons of any age group, but it ismost common in children aged 3-7 years. Boys are affected slightly more often than

girls. Patients with glomerulonephritis may have loss of appetite, lethargy, dull backpain, and dark urine. Blood pressure may be elevated, and edema may occur.

Scarlet fever is a self-limited exanthem that spreads from the chest and abdomen

o the entire body. Tiny red papules create a rough skin texture similar to that of sandpaper. The rash is typically blanching. Although it commonly affects the face,

circumoral pallor is present. During recovery, the skin on the fingers and toes peels.Streptococcal toxic shock syndrome may also occur, affecting skin and mucosa.

PANDAS is a rare syndrome in children and adolescents, who experience suddenonset or worsening of obsessive-compulsive disorder following streptococcalinfection. Associated manifestations include tics and a variety of neuropsychiatric

symptoms.[30]

Complications of mononucleosis

Complications can include the following:

Splenic rupture

HepatitisGuillain-Barré syndrome

EncephalitisHemolytic anemia

AgranulocytosisMyocarditis





Burkitt lymphoma

Nasopharyngeal carcinomaRash (with concomitant use of ampicillin)

Complications of diphtheria

Complications may include airway obstruction, myocarditis, polyneuritis,hrombocytopenia, and proteinuria. Among patients who survive diphtheria, as many

as 20% have permanent hearing loss or other long-term sequelae. [13]

Complications from pertussis

More than half of infants younger than 12 months who contract pertussis requirehospitalization, especially those who are younger than 6 months. Complications of

pertussis in hospitalized infants include the following[28] :

Apnea (50%)Pneumonia (20%)Seizures (1%)

Encephalopathy (0.3%)Death (1%)

In addition, severe cough may result in rib fractures, hernia, incontinence, or subconjunctival hemorrhages.

Complications of influenza

These include the following:

Bacterial superinfection

PneumoniaVolume depletion

Myositis

PericarditisRhabdomyolysisEncephalitisMeningitis

MyelitisRenal failure

Disseminated intravascular coagulation

As with any systemic inf ection, the flu poses a risk of worsening underlying m edical

conditions, such as heart failure, asthma, or diabetes. After influenzal infection,children may experience sinus problems or otitis media.

Patient Education

Address the patient's expectations about antibiotic therapy. Validate t he patient's

symptoms and their severity, listen to the concerns expressed, and educate thepatient about possible consequences of inappropriate antibiotic use, including

consequences affecting him/her and the community.

Many people hold misperceptions about the duration and intensity of symptomsassociated with URI and about the benefits and risks of antibiotic therapy. Some

are unaware that cold symptoms may last as long as 14 days. Some believe thatantibiotics will help them to avoid serious disease and recover more quickly than

without treatment.

Patients may expect to receive antibiotics solely based on the severity of their symptoms, and they may not appreciate the negative consequences of using

antibiotics in viral disease. Negative results on a rapid strep test may providereassurance about the appropriateness of supportive care.

Actively promote self-care, and outline a realistic tim e course for the resolution of symptoms. Reassure the patient about access to clinical care and follow-up in the

event that symptoms progress. Briefly explore factors that may have contributed tohe current infection, and address prevention for the future.

Patient satisfaction is less linked to antibiotic prescriptions and more linked to the

quality of the physician-patient interaction. Reflecting understanding of the details of

he patient's situation, expressing concern for the patient's well-being, explaininghow recommendations are appropriately tailored to the individual's current condition,and providing reassurance are important to patient satisfaction.

Patients should be counseled on handwashing and proper methods of covering

coughs and sneezes. Patients who smoke should receive smoking cessationencouragement and materials. When antibiotics are prescribed, patients should be

instructed to complete the full course of antibiotic therapy.

Patients should be instructed to follow up when indicated or if symptoms worsen.Finally, patients with infectious mononucleosis should be instructed to avoid contact

sports for 6 weeks because of the possibility of splenic rupture.

For patient education information, see the Headache and Migraine Center , as well

as Sinus Infection and Sore Throat.

Clinical Presentation

Contributor Information and Disclosures

Author Anne Meneghetti, MD Assistant Professor of Medicine, Tufts University School of Medicine; Medical

Broadcaster, MyWell-Being.com

Anne Meneghetti, MD is a member of the following medical societies: National Ayurvedic Medical Association

Disclosure: Nothing to disclose.

http://www.ayurvedanama.org/

http://emedicine.medscape.com/article/302460-clinical

http://www.emedicinehealth.com/sore_throat/article_em.htm

http://www.emedicinehealth.com/sinus_infection/article_em.htm

http://www.emedicinehealth.com/script/main/art.asp?articlekey=60057





Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine,Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild LungInstitute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest

Physicians, American College of Physicians, American Federation for Medical Research, American ThoracicSociety


Acknowledgements

Gregory William Rutecki, MD Professor of Medicine, Fellow of The Center for Bioethics and Human Dignity,University of South Alabama College of Medicine

Gregory William Rutecki, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanCollege of Physicians, American Society of Nephrology, National Kidney Foundation, and Society of General

Internal Medicine


Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College

of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Upper Respiratory Tract Infection_ Practice Essentials, Background, Pathophysiology

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