Clinical and laboratory characteristics of viral lower respiratory tract infections in preschool children

Clinical profile of children with influenza like illness during pre-monsoon at coastal Karaikal, Puducherry, India

Influenza infections in developing countries are under reported and WHO estimates that nearly 99% of influenza deaths worldwide occur in children under-five years of age in Asian and African countries. Consequently, this study aims to analyze the use of clinical profile and easily available laboratory parameters to aid identification of the possible viral etiology in the setting of pre-monsoon ILI. A cross-sectional study was carried out for three months among children with ILI attending fever clinic of a tertiary care hospital in Karaikal, South India. In the study population the prevalence of ILI was highest in the age group four to five years followed by school aged children. Adolescents were affected the least. Influenza B was most common virus causing ILI in this region, followed by covid-19 infection. Laboratory parameters depicted a significantly high ESR in COVID-19 infected ILI children. They also exhibited leucopenia and normal platelet counts. Clinical symptoms and laboratory parameters which are easily available and cheaper can be used in resource poor settings of healthcare to identify possible influenza and COVID-19 infected children amongst cases presenting with ILI.

Complicating Infections Associated with Common Endemic Human Respiratory Coronaviruses

Coronaviruses OC43, 229E, NL63, and HKU1 are endemic human respiratory coronaviruses that typically cause mild to moderate upper respiratory infections, similar to the common cold. They also may cause simple and complicated lower respiratory infections, otitis media, asthma exacerbations, gastroenteritis, and a few systemic complications. These viruses are usually seasonal (with winter dominance) and affect nearly all age groups. The seasonal and annual variation in virus prevalence has implications for understanding the concept of acquired immunity and its persistence or diminution. Coronaviruses generally have outbreak potential in susceptible populations of any age, particularly in patients with comorbidities, who tend to have increased clinical disease. These 4 coronaviruses are often found in the context of what appears to be coinfection with other pathogens, but especially other viruses. If coronaviruses are not specifically tested for, the sole detection of a viral copathogen would suggest the pathogen is the causative agent, when a coronavirus may be culpable, or both. The detection of these viruses in circumstances where respiratory viruses are generally sought in clinical samples is, therefore, justified. These pathogens can be chronically shed from the respiratory tract, which is more likely to occur among immunocompromised and complicated patients. These viruses share the potential for genetic drift. The genome is among the largest of RNA viruses, and the capability of these viruses to further change is likely underestimated. Given the potential disease among humans, it is justified to search for effective antiviral chemotherapy for these viruses and to consider uses in niche situations should effective therapy be defined. Whereas SARS-CoV-2 may follow the epidemiological pattern of SARS-CoV and extinguish slowly over time, there is yet concern that SARS-CoV-2 may establish itself as an endemic human respiratory coronavirus similar to OC43, 2299E, NL63, and HKU1. Until sufficient data are acquired to better understand the potential of SARS-CoV-2, continued work on antiviral therapy and vaccination is imperative.

The clinical impact of PCR-based point-of-care diagnostic in respiratory tract infections in children

Background

Children are commonly affected by respiratory tract infections. Based on clinical symptoms, laboratory evaluation, and imaging, the causative pathogen often cannot be delineated. Point‐of‐care‐testing systems that provide an opportunity for fast detection of common viruses and some bacteria can therefore influence treatment's options. We aimed to examine whether the Biofire® FilmArray® has an effect on antibiotic treatment, duration of antibiotic therapy, and length of hospital stay within a pediatric cohort.

Methods

We included children who were admitted to inpatient treatment with an acute respiratory tract infection from 02/2017 to 04/2018 using the FA respiratory panel for pathogen detection. The study group data were compared to the retrospective data of children admitted from 02/2016 to 02/2017, using a proprietary multiplex RT‐PCR.

Results

A total of 322 children of the study group and 464 children of the control group were analyzed for clinical symptoms, laboratory findings, antibiotic treatment, and length of hospital stay. There was no significant reduction (P < .05) of antibiotic treatment and length of hospital stay. CRP, prehospital antibiotic treatment, antibiotic treatment, past medical history, age, and further pathogen detection showed a significant impact on antibiotic therapy, duration of antibiotic treatment, and length of hospital stay.

Conclusion

The use of the FA did not result in a significant reduction of antibiotic treatment or in length of hospital stay. Other parameters had a more significant impact. Therefore, we suggest that standard operation procedures with therapy guidelines are necessary to provide an effective application of POCT systems.

Severe Pulmonary Infection in a 20-Month-Old Female

Community-Acquired Pneumonia (CAP) is a common reason for hospitalization of a pediatric patient. We report a 20-month-old female admitted for suspected CAP. History included a week-long cough, fever, dyspnea, single occurrence of seizure-like activity, and a sick contact. Initial chest X-ray (CXR) showed left lower lobe pneumonia and parapneumonic effusion with a complex left pleural effusion. Ultrasound findings prompted the need for contrast-enhanced computed tomography (CT) of the chest. Contrast-enhanced CT of the chest confirmed a large pleural effusion with major atelectasis and mediastinal shift. The patient was treated with empiric antibiotics, video-assisted thoracoscopic surgical (VATS) decortication of empyema, and chest tube placement. Due to intraoperative complications, the VATS decortication was aborted and patient was transferred to the pediatric intensive care unit (PICU). A thoracentesis with culture failed to isolate a bacterial organism. Dexamethasone was started after repeat CXR showed persistent infiltrate. Subsequent contrast-enhanced CT of the chest showed a large collection of air and persistent consolidation. The patient received repeat VATS decortication and reinsertion of a chest tube. Repeat pleural fluid cultures failed to isolate a bacterial organism. Infectious disease (ID) consult recommended linezolid 140 mg Q8H for 4 weeks. Seven days after second VATS, a respiratory pathogen panel was positive for rhinovirus/enterovirus. With resolution of leukocytosis and clinical improvement, the patient was discharged with the chest tube in place and pediatric surgery outpatient follow-up. After three months, sequalae from both the infection and interventions presented .

The Role of Viral Coinfection in Bronchiolitis Treated With High-Flow Nasal Cannula at Pediatric Emergency Department During 2 Consecutive Seasons: An Observational Study

BACKGROUND

The role of multiple respiratory viruses in bronchiolitis treated with high-flow nasal cannula (HFNC) has not been thoroughly investigated. We evaluated the contribution of coinfection on clinical course of bronchiolitis treated with HFNC and on response to this treatment.

METHODS

We selected 120 children with bronchiolitis, younger than 12 months, admitted to Emergency Department between 2016 and 2018 and treated with HFNC. We compared single and multiple virus infections in relation to specific outcomes such as the clinical response to HFNC and the HFNC failure. The multiple virus infection was defined by the detection of 2 or more viruses in nasopharyngeal aspirates. The HFNC failure was defined as escalation to higher level of care, including Helmet-Continuous Positive Airway Pressure, invasive ventilation or transfer to pediatric intensive care unit within 48 hours from the time of HFNC initiation. We also performed a comparison between HFNC failure and HFNC not-failure groups according to the number of virus and the type of virus.

RESULTS

The severity score post-HFNC initiation was significantly associated with coinfection [odds ratio (OR): 1.361; 95% confidence interval (CI): 1.036-1.786; P = 0.027]. The likelihood of coinfection decreased by 23.1% for each increase of saturation O2 after HFNC initiation (OR: 0.769; 95% CI: 0.609-0.972; P = 0.028). Atelectasis was more likely to occur in coinfection (OR: 2.923; 95% CI: 1.049-8.148; P = 0.04). The duration of HFNC treatment increased significantly in coinfection (OR: 1.018; 95% CI: 1.006-1.029; P = 0.002). No significant differences were described between HFNC failure and the number and the type of detected viruses.

CONCLUSIONS

The detection of multiple viruses and the type of virus did not influence the HFNC failure, although the coinfection was associated with a deterioration of severity score, a longer HFNC treatment and a major presence of atelectasis. The role of coinfection on HFNC treatment might subtend a complex interplay between multiple viruses and host susceptibility.

Characteristics of Hospitalized Rhinovirus-Associated Community-Acquired Pneumonia in Children, Finland, 2003-2014

Background: Rhinovirus (RV) is the most common cause of respiratory tract infections in children but, still, the clinical characteristics of RV-associated pneumonia have not been sufficiently investigated.

Methods: We identified children and adolescents younger than 18 years of age treated for community-acquired pneumonia as inpatients at the Turku University Hospital from 2003 to 2014 and analyzed for RV by PCR of a respiratory tract specimen. We collected the data from medical records and compared RV-positive children with RV-negative children.

Results: Of the study population of 313 children with pneumonia who were studied for RV, it was detected in 82 (26%). RV-positive children were younger (median age 2.6 years, interquartile range [IQR] 1.1–4.6 vs. 3.5 years, IQR 1.7–8.3, p = 0.002) and they had more often a history of preterm birth (16% vs. 5%, adjusted odds ratio 2.89, 95% confidence interval 1.21–6.92, p = 0.017) than RV-negative children. RV-positive children had a higher median white blood cell count than RV-negative children at presentation with pneumonia. The signs, symptoms, and severity of pneumonia were mostly similar in RV-positive and RV-negative children.

Conclusions: RV was frequently detected in young children hospitalized with community-acquired pneumonia. We identified premature birth as a factor associated with RV-positive pneumonia. The clinical features of pneumonia did not clearly differ between RV-positive and RV-negative children. Further studies are needed to clarify the clinical significance of detection of RV in children with pneumonia.

White L, Poovorawan K, Soonthornworasiri N, Sukontamarn P, Chanthavilay P, F. Medley G, Pan-ngum W. Modeling household dynamics on Respiratory Syncytial Virus (RSV)

Respiratory Syncytial Virus (RSV) is the most common cause of respiratory tract infection in infants and children and shows increasing trend among elderly people worldwide. In many developing country settings, population and household structures have gone through some significant changes in the past decades, namely fewer births, more elderly population, and smaller household size but more RSV high-risk individuals. These dynamics have been captured in a mathematical model with RSV transmission dynamics to predict the disease burden on the detailed population for future targeted interventions. The population and disease dynamics model was constructed and tested against the hospitalization data for Acute Lower Respiratory Tract Infection due to RSV in rural Thai settings between 2005 and 2011. The proportion of extended families is predicted to increase by about 10% from 2005 to 2020, especially for those with elderly population, while the classic nuclear family type (with adults and children) will decline by about 10%. For RSV, infections from extended family type (approximately 60% of all household types) have majorly contributed to the force of infection (FOI). While the model predicted the increase of FOI from the extended family by 15% from 2005 to 2020, the FOI contributed by other household types would be either stable or decrease in the same time period. RSV incidence rate is predominantly high among babies (92.2%) and has been predicted to decrease slightly over time (from 940 to 864 cases per 100,000 population by 2020), while the incidence rates among children and elderly people may remain steadily low over the same period. However, the estimated incidence rates among elderly people were twice than those in children. The model predicts that approximately 60% of FOI for RSV will come from members of the extended family type. The incidence rate of RSV among children and elderly in extended families was about 20 times lower than that in infants and the trend is steady. Targeted intervention strategies, such as health education in some specific groups and targeted vaccination, may be considered, with the focus on extended family type. Target interventions on babies can lessen the transmission to children and elderly especially when transmission within households of extended family type is high.