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Grimwood K, Bell SC, Chang AB. Antimicrobial treatment of non-cystic fibrosis bronchiectasis. Expert Rev Anti Infect Ther 2014; 12:1277-96. [PMID: 25156239 DOI: 10.1586/14787210.2014.952282] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bronchiectasis unrelated to cystic fibrosis is characterized by chronic wet or productive cough, recurrent exacerbations and irreversible bronchial dilatation. After antibiotics and vaccines became available and living standards in affluent countries improved, its resulting reduced prevalence meant bronchiectasis was considered an 'orphan disease'. This perception has changed recently with increasing use of CT scans to diagnose bronchiectasis, including in those with severe chronic obstructive pulmonary disease or 'difficult to control' asthma, and adds to its already known importance in non-affluent countries and disadvantaged Indigenous communities. Following years of neglect, there is renewed interest in identifying the pathogenetic mechanisms of bronchiectasis, including the role of infection, and conducting clinical trials. This is providing much needed evidence to guide antimicrobial therapy, which has relied previously upon extrapolating treatments used in cystic fibrosis and chronic obstructive pulmonary disease. While many knowledge gaps and management challenges remain, the future is improving for patients with bronchiectasis.
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Affiliation(s)
- Keith Grimwood
- Griffith Health Institute, Griffith University, Gold Coast, QLD 4222, Australia
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52
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McGuigan L, Callaghan M. The evolving dynamics of the microbial community in the cystic fibrosis lung. Environ Microbiol 2014; 17:16-28. [DOI: 10.1111/1462-2920.12504] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/28/2014] [Accepted: 05/01/2014] [Indexed: 12/29/2022]
Affiliation(s)
- Luke McGuigan
- Department of Science; Centre of Microbial Host Interactions (CMHI); ITT-Dublin; Dublin Ireland
| | - Máire Callaghan
- Department of Science; Centre of Microbial Host Interactions (CMHI); ITT-Dublin; Dublin Ireland
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53
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Ramirez IA, Caverly LL, Kalikin LM, Goldsmith AM, Lewis TC, Burke DT, LiPuma JJ, Sajjan US, Hershenson MB. Differential responses to rhinovirus- and influenza-associated pulmonary exacerbations in patients with cystic fibrosis. Ann Am Thorac Soc 2014; 11:554-61. [PMID: 24641803 PMCID: PMC4225796 DOI: 10.1513/annalsats.201310-346oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/26/2014] [Indexed: 12/25/2022] Open
Abstract
RATIONALE The mechanism by which viruses cause exacerbations of chronic airway disease and the capacity of patients with cystic fibrosis (CF) to respond to viral infection are not precisely known. OBJECTIVES To determine the antiviral response to infection in patients with CF. METHODS Sputum was collected from patients with CF with respiratory exacerbation. Viruses were detected in multiplex polymerase chain reaction (PCR)-based assays. Gene expression of 84 antiviral response genes was measured, using a focused quantitative PCR gene array. MEASUREMENTS AND MAIN RESULTS We examined 36 samples from 23 patients with respiratory exacerbation. Fourteen samples tested virus-positive and 22 virus-negative. When we compared exacerbations associated with rhinovirus (RV, n = 9) and influenza (n = 5) with virus-negative specimens, we found distinct patterns of antiviral gene expression. RV was associated with greater than twofold induction of five genes, including those encoding the monocyte-attracting chemokines CXCL10, CXCL11, and CXCL9. Influenza was associated with overexpression of 20 genes, including those encoding the cytokines tumor necrosis factor and IL-12; the kinases MEK, TBK-1, and STAT-1; the apoptosis proteins caspase-8 and caspase-10; the influenza double-stranded RNA receptor RIG-I and its downstream effector MAVS; and pyrin, an IFN-stimulated protein involved in influenza resistance. CONCLUSIONS We conclude that virus-induced exacerbations of CF are associated with immune responses tailored to specific infections. Influenza induced a more potent response consisting of inflammation, whereas RV infection had a pronounced effect on chemokine expression. As far as we are aware, this study is the first to compare specific responses to different viruses in live patients with chronic airway disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Marc B. Hershenson
- Department of Pediatrics and Communicable Diseases
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan
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54
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Abstract
Survival has improved in patients with cystic fibrosis (CF), in part because of aggressive antimicrobial management. Two multidrug-resistant environmental bacteria, the Burkholderia cepacia group and nontuberculous mycobacteria, have emerged. Improving genomic and proteomic technologies are allowing better identification of bacteria and fungi found in the CF lung and detection of viral agents that may be associated with pulmonary exacerbations. Anaerobic bacteria and Streptococcus angionsus group organisms may play a role in chronic CF lung infections. The diversity of organisms declines perhaps as a result of aggressive antimicrobial therapy, and an apex predator, Pseudomonas aeruginosa, may emerge in many patients with CF.
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55
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Lopes SP, Azevedo NF, Pereira MO. Microbiome in cystic fibrosis: Shaping polymicrobial interactions for advances in antibiotic therapy. Crit Rev Microbiol 2014; 41:353-65. [PMID: 24645634 DOI: 10.3109/1040841x.2013.847898] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recent molecular methodologies have demonstrated a complex microbial ecosystem in cystic fibrosis (CF) airways, with a wide array of uncommon microorganisms co-existing with the traditional pathogens. Although there are lines of evidence supporting the contribution of some of those emergent species for lung disease chronicity, clinical significance remains uncertain for most cases. A possible contribution for disease is likely to be related with the dynamic interactions established between microorganisms within the microbial community and with the host. If this is the case, management of CF will only be successful upon suitable and exhaustive modulation of such mixed ecological processes, which will also be useful to predict the effects of new therapeutic interventions.
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Affiliation(s)
- Susana P Lopes
- IBB-CEB, Institute for Biotechnology and Bioengineering, Centre of Biological Engineering, University of Minho, Campus de Gualtar , Braga , Portugal and
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56
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Gangell CL, Shackleton C, Poreddy S, Kappers J, Gaydon JE, Sloots TP, Stick SM, Ranganathan SC, Sly PD. Feasibility of parental collected nasal swabs for virus detection in young children with cystic fibrosis. J Cyst Fibros 2014; 13:661-6. [PMID: 24637444 PMCID: PMC7105194 DOI: 10.1016/j.jcf.2014.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/04/2014] [Accepted: 02/24/2014] [Indexed: 11/12/2022]
Abstract
Background The detrimental role of viruses has been well described in CF, although the pattern of virus infections has not been investigated in a longitudinal study. The primary aim was to determine the feasibility of fortnightly parent collected swabs in young children with CF. Methods Children under three years with CF were recruited. Nasal swabs were collected by parents every fortnight and during periods of symptoms over 12 months. Nasal swabs were posted and virus detected using real-time PCR. Results Only 27% of the patients completed the study to 10 months, although 98% of the swabs returned were adequate for analysis. Mould was observed growing on 23% of the returned swabs. There was no evidence to demonstrate relationships with symptoms and viruses, prolonged symptoms, prolonged shedding or patterns of virus infections. Conclusions This study highlights the need to further investigate the role of viruses in children with CF using a robust method of frequent collection in children for a longitudinal study, with appropriate storage and shipping techniques to avoid mould growth or other potential contaminants.
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Affiliation(s)
- C L Gangell
- Queensland Children's Medical Research Institute, The University of Queensland, Herston, Queensland 4029, Australia.
| | - C Shackleton
- Queensland Children's Medical Research Institute, The University of Queensland, Herston, Queensland 4029, Australia
| | - S Poreddy
- Centre for Child Health Research, The University of Western Australia, Subiaco, Western Australia 6008, Australia
| | - J Kappers
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria 3052, Australia
| | - J E Gaydon
- Queensland Children's Medical Research Institute, The University of Queensland, Herston, Queensland 4029, Australia; Queensland Paediatric Infectious Diseases Laboratory, Royal Children's Hospital, Brisbane, Queensland 4029, Australia
| | - T P Sloots
- Queensland Children's Medical Research Institute, The University of Queensland, Herston, Queensland 4029, Australia; Queensland Paediatric Infectious Diseases Laboratory, Royal Children's Hospital, Brisbane, Queensland 4029, Australia
| | - S M Stick
- Centre for Child Health Research, The University of Western Australia, Subiaco, Western Australia 6008, Australia
| | - S C Ranganathan
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Victoria 3052, Australia
| | - P D Sly
- Queensland Children's Medical Research Institute, The University of Queensland, Herston, Queensland 4029, Australia
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57
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Goffard A, Lambert V, Salleron J, Herwegh S, Engelmann I, Pinel C, Pin I, Perrez T, Prévotat A, Dewilde A, Delhaes L. Virus and cystic fibrosis: rhinoviruses are associated with exacerbations in adult patients. J Clin Virol 2014; 60:147-53. [PMID: 24637203 PMCID: PMC7108260 DOI: 10.1016/j.jcv.2014.02.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/27/2014] [Accepted: 02/17/2014] [Indexed: 12/22/2022]
Abstract
Background Few studies have suggested the potential role of respiratory viruses in cystic fibrosis (CF) exacerbation, but their real impact is probably underestimated. Method Sixty-four sputum samples collected from 46 adult patients were included in the study: 33 samples were collected during exacerbation of CF, and 31 during the stable phase. After extraction, nucleic acids were tested for the presence of respiratory viruses. When rhinovirus (HRV) was detected, the 5′UTR and VP4/2 regions were sequenced, and phylogenetically analyzed. The characteristics of patients in exacerbation and stable phase were compared. Results Viruses were found in 25% of samples. The HRV viruses were the most frequently detected followed by coronaviruses. Only the HRV detection was significantly associated with the occurrence of CF pulmonary exacerbation (p < 0.027). Characterization of 5′UTR and VP4/2 regions of the HRV genome specified that HRV-A, -B, -C were detected. All HRV-C were recombinant HRV-Ca. Conclusions HRV were the most frequently detected viruses; their detection was significantly associated with the occurrence of an exacerbation. The reality of viral recombination between HRV was demonstrated in CF patients for the first time, raising the role of viruses in lung microbiota. Further studies are now warranted to decipher virus impact in CF.
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Affiliation(s)
- Anne Goffard
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France; Molecular & Cellular Virology of Hepatitis C, Center of Infection and Immunity of Lille (CIIL), Inserm U1019, CNRS UMR 8204, Univ. Lille North of France.
| | - Valérie Lambert
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France
| | - Julia Salleron
- Department of Biostatistics, Lille Hospital, Faculty of Medicine, Lille, France
| | - Stéphanie Herwegh
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France
| | - Ilka Engelmann
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France; Lille 2 University, Lille Hospital, Faculty of Medicine, Laboratoire de Virologie/EA3610, Lille, France
| | - Claudine Pinel
- Department of Parasitology-Mycology, Grenoble Hospital, France
| | - Isabelle Pin
- Department of Pneumology and Immuno-Allergology, Grenoble Hospital, France
| | - Thierry Perrez
- Department of Pneumology and Immuno-Allergology, CRCM adulte, Calmette Hospital, Lille, France
| | - Anne Prévotat
- Department of Pneumology and Immuno-Allergology, CRCM adulte, Calmette Hospital, Lille, France
| | - Anny Dewilde
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France
| | - Laurence Delhaes
- Department of Microbiology, Lille Hospital, Faculty of Medicine, Lille, France; Center of Infection and Immunology of Lille (CIIL), Institut Pasteur, Biology and Diversity of Emerging Eukaryotic Pathogens (BDEEP - EA4547), Lille, France; INSERM U1019, Lille, France
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58
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Principi N, Daleno C, Esposito S. Human rhinoviruses and severe respiratory infections: is it possible to identify at-risk patients early? Expert Rev Anti Infect Ther 2014; 12:423-30. [PMID: 24559383 DOI: 10.1586/14787210.2014.890048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Molecular methods of viral screening have demonstrated that human rhinoviruses (HRVs) are associated with lower respiratory tract infections (LRTIs, including bronchiolitis and pneumonia), exacerbations of chronic pulmonary disease and the development of asthma. Patients with severe chronic diseases are at greater risk of developing major clinical problems when infected by HRVs, particularly if they are immunocompromised or have a chronic lung disease. Analysing the characteristics of HRVs does not provide any certainty concerning the risk of a poor prognosis and, although viremia seems to be associated with an increased risk of severe HRV infection, the available data are too scanty to be considered conclusive. However, a chest x-ray showing alveolar involvement suggests the potentially negative evolution of a bacterial superinfection. There is therefore an urgent need for more effective diagnostic, preventive and therapeutic measures in order to prevent HRV infection, and identify and treat the patients at highest risk.
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Affiliation(s)
- Nicola Principi
- Department of Pathophysiology and Transplantation, Pediatric High Intensity Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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59
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Berkebile AR, McCray PB. Effects of airway surface liquid pH on host defense in cystic fibrosis. Int J Biochem Cell Biol 2014; 52:124-9. [PMID: 24560894 DOI: 10.1016/j.biocel.2014.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/01/2014] [Accepted: 02/11/2014] [Indexed: 01/27/2023]
Abstract
Cystic fibrosis is a lethal genetic disorder characterized by viscous mucus and bacterial colonization of the airways. Airway surface liquid represents a first line of pulmonary defense. Studies in humans and animal models of cystic fibrosis indicate that the pH of airway surface liquid is reduced in the absence of cystic fibrosis transmembrane conductance regulator function. Many aspects of the innate host defense system of the airways are pH sensitive, including antimicrobial peptide/protein activity, the rheological properties of secreted mucins, mucociliary clearance, and the activity of proteases. This review will focus on how changes in airway surface liquid pH may contribute to the host defense defect in cystic fibrosis soon after birth. Understanding how changes in pH impact mucosal immunity may lead to new therapies that can modify the airway surface liquid environment, improve airway defenses, and alter the disease course.
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Affiliation(s)
- Abigail R Berkebile
- Department of Microbiology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Paul B McCray
- Department of Microbiology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA; Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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60
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Renk H, Regamey N, Hartl D. Influenza A(H1N1)pdm09 and cystic fibrosis lung disease: a systematic meta-analysis. PLoS One 2014; 9:e78583. [PMID: 24427261 PMCID: PMC3888399 DOI: 10.1371/journal.pone.0078583] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/27/2013] [Indexed: 01/01/2023] Open
Abstract
Background To systematically assess the literature published on the clinical impact of Influenza A(H1N1)pdm09 on cystic fibrosis (CF) patients. Methods An online search in PUBMED database was conducted. Original articles on CF patients with Influenza A(H1N1)pdm09 infection were included. We analyzed incidence, symptoms, clinical course and treatment. Results Four surveys with a total of 202 CF patients infected by Influenza A(H1N1)pdm09 were included. The meta-analysis showed that hospitalisation rates were higher in CF patients compared to the general population. While general disease symptoms were comparable, the clinical course was more severe and case fatality rate (CFR) was higher in CF patients compared to asthmatics and the general population. Conclusions Evidence so far suggests that CF patients infected with Influenza A(H1N1)pdm09 show increased morbidity and a higher CFR compared to patients with other chronic respiratory diseases and healthy controls. Particularly, CF patients with advanced stage disease seem to be more susceptible to severe lung disease. Accordingly, early antiviral and antibiotic treatment strategies are essential in CF patients. Preventive measures, including vaccination as well as hygiene measures during the influenza season, should be reinforced and improved in CF patients.
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Affiliation(s)
- Hanna Renk
- University Children's Hospital, Eberhard-Karls-University, Tuebingen, Germany
| | - Nicolas Regamey
- Department of Paediatrics, Inselspital and University of Bern, Bern, Switzerland
| | - Dominik Hartl
- University Children's Hospital, Eberhard-Karls-University, Tuebingen, Germany
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61
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Esposito S, Dacc^|^ograve; V, Daleno C, Gambazza S, Montinaro V, Bisogno A, Principi N, Colombo C. Human Rhinovirus Infection in Children with Cystic Fibrosis. Jpn J Infect Dis 2014. [DOI: 10.7883/yoken.67.399] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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62
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Aliouat-Denis CM, Chabé M, Delhaes L, Dei-Cas E. Aerially transmitted human fungal pathogens: what can we learn from metagenomics and comparative genomics? Rev Iberoam Micol 2013; 31:54-61. [PMID: 24286763 DOI: 10.1016/j.riam.2013.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/04/2013] [Indexed: 12/25/2022] Open
Abstract
In the last few decades, aerially transmitted human fungal pathogens have been increasingly recognized to impact the clinical course of chronic pulmonary diseases, such as asthma, cystic fibrosis or chronic obstructive pulmonary disease. Thanks to recent development of culture-free high-throughput sequencing methods, the metagenomic approaches are now appropriate to detect, identify and even quantify prokaryotic or eukaryotic microorganism communities inhabiting human respiratory tract and to access the complexity of even low-burden microbe communities that are likely to play a role in chronic pulmonary diseases. In this review, we explore how metagenomics and comparative genomics studies can alleviate fungal culture bottlenecks, improve our knowledge about fungal biology, lift the veil on cross-talks between host lung and fungal microbiota, and gain insights into the pathogenic impact of these aerially transmitted fungi that affect human beings. We reviewed metagenomic studies and comparative genomic analyses of carefully chosen microorganisms, and confirmed the usefulness of such approaches to better delineate biology and pathogenesis of aerially transmitted human fungal pathogens. Efforts to generate and efficiently analyze the enormous amount of data produced by such novel approaches have to be pursued, and will potentially provide the patients suffering from chronic pulmonary diseases with a better management. This manuscript is part of the series of works presented at the "V International Workshop: Molecular genetic approaches to the study of human pathogenic fungi" (Oaxaca, Mexico, 2012).
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Affiliation(s)
- Cécile-Marie Aliouat-Denis
- Biology & Diversity of Emerging Eukaryotic Pathogens (BDEEP), Center for Infection and Immunity of Lille (CIIL), INSERM U1019, CNRS UMR8204, IFR142, Lille Pasteur Institute, Lille Nord de France University (EA4547), Lille, France; Parasitology-Medical Mycology Department, Faculty of Pharmacy, Lille, France
| | - Magali Chabé
- Biology & Diversity of Emerging Eukaryotic Pathogens (BDEEP), Center for Infection and Immunity of Lille (CIIL), INSERM U1019, CNRS UMR8204, IFR142, Lille Pasteur Institute, Lille Nord de France University (EA4547), Lille, France; Parasitology-Medical Mycology Department, Faculty of Pharmacy, Lille, France
| | - Laurence Delhaes
- Biology & Diversity of Emerging Eukaryotic Pathogens (BDEEP), Center for Infection and Immunity of Lille (CIIL), INSERM U1019, CNRS UMR8204, IFR142, Lille Pasteur Institute, Lille Nord de France University (EA4547), Lille, France; Parasitology-Medical Mycology Department, Regional Hospital Center, Faculty of Medicine, Lille, France.
| | - Eduardo Dei-Cas
- Biology & Diversity of Emerging Eukaryotic Pathogens (BDEEP), Center for Infection and Immunity of Lille (CIIL), INSERM U1019, CNRS UMR8204, IFR142, Lille Pasteur Institute, Lille Nord de France University (EA4547), Lille, France; Parasitology-Medical Mycology Department, Regional Hospital Center, Faculty of Medicine, Lille, France
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63
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Esposito S, Daleno C, Scala A, Castellazzi L, Terranova L, Sferrazza Papa S, Longo MR, Pelucchi C, Principi N. Impact of rhinovirus nasopharyngeal viral load and viremia on severity of respiratory infections in children. Eur J Clin Microbiol Infect Dis 2013; 33:41-8. [PMID: 23893065 PMCID: PMC7088146 DOI: 10.1007/s10096-013-1926-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/05/2013] [Indexed: 11/26/2022]
Abstract
There are few and partially discordant data regarding nasopharyngeal rhinovirus (RV) load and viremia, and none of the published studies evaluated the two variables together. The aim of this study was to provide new information concerning the clinical relevance of determining nasopharyngeal viral load and viremia when characterising RV infection. Nasopharyngeal swabs were obtained from 251 children upon their admission to hospital because of fever and signs and symptoms of acute respiratory infection in order to identify the virus and determine its nasopharyngeal load, and a venous blood sample was taken in order to evaluate viremia. Fifty children (19.9 %) had RV-positive nasopharyngeal swabs, six (12 %) of whom also had RV viremia: RV-C in four cases (66.6 %), and RV-A and RV-B in one case each. The RV nasopharyngeal load was significantly higher in the children with RV viremia (p < 0.001), who also had a higher respiratory rate (p = 0.02), white blood cell counts (p = 0.008) and C-reactive protein levels (p = 0.006), lower blood O2 saturation levels (P = 0.005), and more often required O2 therapy (p = 0.009). The presence of RV viremia is associated with a significantly higher nasopharyngeal viral load and more severe disease, which suggests that a high nasopharyngeal viral load is a prerequisite for viremia, and that viremia is associated with considerable clinical involvement.
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Affiliation(s)
- S Esposito
- Pediatric Clinic 1, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milano, Italy,
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