Management of complicated pediatric rhinosinusitis in the COVID-19 era

With the ongoing development of the COVID-19 pandemic, research continues to emerge regarding the pathophysiology, characteristics, and treatment considerations for patients with COVID-19. No reports have highlighted the specific challenges posed in the management of pediatric patients with COVID-19 who present with complicated rhinosinusitis. In this report, we discuss our preoperative, intraoperative, and postoperative multidisciplinary treatment strategy for these cases and provide two examples of complicated rhinosinusitis cases in COVID-19 patients, treated with two different approaches. Pearls, insights, and a brief review of the literature are discussed.

Patterns of viral pathogens causing upper respiratory tract infections among symptomatic children in Mwanza, Tanzania

Upper-respiratory tract infections (URTI) are the leading causes of childhood morbidities. This study investigated etiologies and patterns of URTI among children in Mwanza, Tanzania. A cross-sectional study involving 339 children was conducted between October-2017 and February-2018. Children with features suggestive of URTI such as nasal congestion, dry cough, painful swallowing and nasal discharge with/without fever were enrolled. Pathogens were detected from nasopharyngeal and ear-swabs by multiplex-PCR and culture respectively. Full blood count and C-reactive protein analysis were also done. The median age was 16 (IQR: 8-34) months. Majority (82.3%) had fever and nasal-congestion (65.5%). Rhinitis (55.9%) was the commonest diagnosis followed by pharyngitis (19.5%). Viruses were isolated in 46% of children, the commonest being Rhinoviruses (23.9%). Nineteen percent of children had more than 2 viruses; Rhinovirus and Enterovirus being the commonest combination. The commonest bacteria isolated from ears were Staphylococcus aureus and Pseudomonas aeruginosa. Children with viral pathogens had significantly right shift of lymphocytes (73%-sensitivity). Majority (257/339) of children were symptoms free on eighth day. Viruses are the commonest cause of URTI with Rhinitis being the common diagnosis. Rapid diagnostic assays for URTI pathogens are urgently needed in low-income countries to reduce unnecessary antibiotic prescriptions which is associated with antibiotic resistance.

Impact of Respiratory Virus Infections in Exacerbation of Acute and Chronic Rhinosinusitis

Rhinosinusitis (RS) is a symptomatic disease classification of many causes and is a major economic burden worldwide. It is widely accepted that RS is further classified into acute (ARS) and chronic (CRS) rhinosinusitis based on the duration of the symptoms, and that viral infection plays a large role in initiating or potentiating the disease. In this review, we examine the role of respiratory virus infection in the exacerbation of ARS and CRS. We explore the epidemiology of viral exacerbation of ARS and CRS and highlight key viruses that may cause exacerbation. We also review the current understanding of viral infections in the upper airway to further explain the putative underlying mechanisms of inflammatory events in ARS and CRS exacerbation. Advances in accurate diagnosis of the etiologic respiratory viruses of ARS and CRS symptoms which can lead to better disease management are also surveyed. In addition to the current treatments which provide symptomatic relief, we also explore the potential of harnessing existing antiviral strategies to prevent ARS and CRS exacerbation, especially with improved viral diagnostic tools to guide accurate prescription of antivirals against causative respiratory viruses.

Herbal drug BNO 1016 is safe and effective in the treatment of acute viral rhinosinusitis

CONCLUSION

Daily intake of 480 mg of BNO 1016 for 15 days is an effective treatment in acute viral rhinosinusitis.

OBJECTIVES

The pooled efficacy data of two similar randomized placebo-controlled clinical trials were analyzed. Safety was evaluated on the basis of the individual trials.

METHODS

The efficacy analysis was based on 589 patients. Treatment was performed orally with either 3 × 160 mg BNO 1016 (n = 294) or 3 × placebo (n = 295) for 15 days. In both trials patients underwent five visits to the investigational sites. Symptoms were evaluated according to the EPOS 2012 guideline. Ultrasonography was used to confirm the diagnosis at onset of treatment and the remission of symptoms at the last visit. Efficacy was evaluated by the investigator as the mean major symptom score (MSS) at the end of treatment (visit 5, day 14). Patients reported symptoms and social/emotional consequences of rhinosinusitis using a quality of life questionnaire (SNOT-20 GAV).

RESULTS

MSS improved during the treatment period by a mean of 10.02 ± 1.61 score points to 2.47 ± 2.55 for BNO 1016 and of 9.87 ± 1.52 to 3.63 ± 3.63 for placebo. Differences between treatment groups at end of therapy (1.16 ± 3.14 score points; p < 0.0001) and patient-assessed quality of life (p = 0.0015) were statistically significant in favor of BNO 1016.

Comparison of viral load in individuals with and without asthma during infections with rhinovirus

RATIONALE

Most virus-induced attacks of asthma are caused by rhinoviruses (RVs).

OBJECTIVES

To determine whether people with asthma are susceptible to an increased viral load during RV infection.

METHODS

Seventy-four children (4-18 yr old) were enrolled; 28 with wheezing, 32 with acute rhinitis, and 14 without respiratory tract symptoms. Nasal washes were evaluated using quantitative polymerase chain reaction for RV to judge viral load along with gene sequencing to identify strains of RV. Soluble intercellular adhesion molecule-1, IFN-λ1, and eosinophil cationic protein in nasal washes, along with blood eosinophil counts and total and allergen-specific IgE in sera, were also evaluated. Similar assessments were done in 24 young adults (16 with asthma, 8 without) who participated in an experimental challenge with RV (serotype 16).

MEASUREMENTS AND MAIN RESULTS

Fifty-seven percent of wheezing children and 56% with acute rhinitis had nasal washes testing positive for RV. The geometric mean of viral loads by quantitative polymerase chain reaction in washes from wheezing children was 2.8-fold lower, but did not differ significantly from children with rhinitis (7,718 and 21,612 copies of viral RNA per microliter nasal wash, respectively; P = 0.48). The odds for wheezing were increased if children who tested positive for RV were sensitized to one or more allergens (odds ratio, 3.9; P = 0.02). Similarly, neither peak nor cumulative viral loads differed significantly in washes from adults with asthma compared with those without asthma during the experimental RV challenge.

CONCLUSIONS

During acute symptoms, children infected with RV enrolled for wheezing or acute rhinitis had similar viral loads in their nasal washes, as did adults with and without asthma infected with RV-16 experimentally.

[The role of respiratory viruses in etiology of rhinosinisitis in the children]

The objective of the present study was to elucidate the role of respiratory viruses in etiology of acute rhinosinusitis (ARS) in the children and adolescents. We analysed the results of a microbiologial study of 50 aspirates from the paranasl sinuses. It was shown that acute rhinosinusitis had bacterial and viral-bacterial etiology in 8% and 24% of the cases respectively. In 42% of the cases the pathogen could not be identified by any of the methods used in the study.

[The etiologic diagnostics of rhinosinusitis using clinical laboratory methods]

The examination was applied to 81 children aged 5-15 years, including 64 children with diagnosis of rhinosinusitis. The control group consisted of 17 healthy children. The set of laboratory clinical diagnostic techniques was applied to detect the causes of pathology. It is established that children with rhinosinusitis suffered from concurrent bacterial and virus infections. The morphologic presentation of mucous membrane of nasal cavity reflects the etiologic factor and the stage of inflammatory process. The detection of concentration of IL-4, IL-6 and IL-8 of blood serum gives a possibility to diagnose children with combined mechanisms of development of rhinosinusitis.

[Rhinoviruses. Frequency in nonhospitalized children with acute respiratory infection]

Molecular methods for human rhinoviruses (HRV) have increased the sensitivity in their diagnosis. HRV may cause acute respiratory infections (ARI) of the upper and lower respiratory tract. HRV infection during childhood is a predictor of asthma development. In this study, the HRV frequency in outpatient children with ARI was determined, and their clinical features and previous conditions were evaluated. A total of 186 respiratory samples of children under 6 year old attending the CEMIC pediatric emergency room from June 1, 2008 to May 31, 2010, were studied. Classical respiratory viruses were detected by immunofluorescence. A real time RT-PCR that amplifies part of the 5' non coding genomic region was used for HRV detection. Viral detection was obtained in 61% of children. The frequency was: 27% for HRV, 16% for respiratory syncytial virus (RSV), 9% for influenza, 8% for parainfluenza, 7% for metapneumovirus and 0.5% for adenovirus. Dual coinfection was detected in 8 children and HRV were the most frequent, detected in 4 of them. HRV circulated during the two year period of the study, with peaks during winter and spring. No clinical difference was observed between patients with or without HRV, except an increase percent of children with HRV without fever. HRV were the most frequent viruses detected in this population, mainly in children under 2 year old, the second cause of bronchiolitis after RSV and more frequently detected in children exposed to passive smoking (OR = 2.91; p = 0.012), and were detected as the sole etiologic agent in 28% of bronchiolitis.

Efficacy of a new medical device based on colloidal silver and carbossimetyl beta glucan in treatment of upper airways disease in children

AIM

Nasal congestion is the main symptom in common upper respiratory diseases in childhood. Intranasal administration of sympatheticomimetics decongestants is commonly adopted for this symptom. The Italian Drug Agency stated a warning against the use of these drugs in children under 12 years of age. The aim of this study is to evaluate the efficacy on nasal symptoms and the safety of a new medical device based on colloidal silver and carbossimetyl beta glucan compared with saline solution treatment in a group of children (0-12 years) affected by viral rhinitis.

METHODS

Hundred consecutive outpatient children (0-12 year old), affected by common cold syndrome with evident nasal obstruction were randomly assigned to two type of intervention: group 1. receiving colloidal silver and carbossimetyl beta glucan; group 2. receiving saline solution. Each subject underwent clinical history and objective examination of rhinosinusal district at enrollment. Upper respiratory pathologie-related symptoms were specifically evaluated by using the Canadian Acute Respiratory Illness and Flu Scale (CARIFS).

RESULTS

A significant improvement of CARIFS score was observed into the two groups. The score improvement of these two treatment was confirmed in all the age sub-group. We observed a statistically significant difference in mean post-treatment CARIFS score and CARIFS globas VAS (Visual Analogic Scale) in children of group 1 compared with children in group 2 (2.28 ± 1.58 vs. 5.08 ± 3.39; P<0.001 and VAS: 1.87 ± 1.38 vs. VAS: 3.34 ± 2.19; P=0.012, respectively). At the end of treatment, 90% of subjects in group 1 resulted completely recovered, whereas 10% experienced some degree of complications (otitis, tracheitis, bronchitis). In group 2 a complete recovering was achieved in 66 % of subjects, the remaining 34 % developed complications. Tolerability profiles were similar in the two groups with no statistical differences in side effects in all age subgroups.

CONCLUSION

Despite both treatments reached significative improvements in CARIFS global score and VAS and in physical examination of nasal mucosa and secretion at the end of the therapy, colloidal silver and carbossimetyl beta glucan showed a better performance with a significant difference in mean post-treatment CARIFS global score and CARIFS VAS compared to treatment with saline solution.

[Rhinitis in adults]

Rhinitis is a very common disorder caused by inflammation or irritation of nasal mucosa. Dominant symptoms are nasal obstruction; however, in some patients, runny nose, excessive sneezing or nasal itch may be the most bothersome symptoms. The most common causes of nasal inflammation are viral infections and allergic response to airborne allergens. Response to irritants may cause similar symptoms, although signs of inflammation may not always be present. Viral rhinitis is lasting up to 10 days and it is part of the common cold syndrome. In short-lived rhinitis, lasting for 7 to 10 days, sometimes it is not easy to differentiate between the potential causes of the disorder, if general symptoms of infection like fever and malaise are not present. In long-living rhinitis, it is important to differentiate between infectious, allergic, non-allergic non-infectious rhinitis, and chronic rhinosinusitis. Itch and ocular symptoms are more common in allergic rhinitis, while other symptoms like nasal obstruction, rhinorrhea and sneezing may affect patients with allergic and non-allergic rhinitis. Patients with allergic rhinitis often have symptoms after exposure to irritants, temperature and humidity changes, like patients with non-allergic rhinitis, and such exposure may sometimes cause more severe symptoms than exposure to allergens. Sensitivity to a non-specific trigger is usually called non-specific nasal hyperreactivity. Allergic rhinitis occurs due to immunoglobulin E (IgE) interaction with allergen in contact with nasal mucosa in a sensitized patient. Sensitization to certain airborne allergen, like pollens, dust, molds, animal dander, etc. usually occurs in families with allergy background, which is helpful in making diagnosis in patients who have rhinitis in a certain period of the year, or aggravation of nasal symptoms occurs in the environment typical of certain allergen. The diagnosis is clinically confirmed by proving sensitivity to certain allergen on skin prick test, and by proving specific antibody IgE in patient serum. Allergic rhinitis is categorized according to sensitivity to allergens that occur seasonally, like pollens, or to allergens that are present all year round, like house dust mite, molds and animal dander, into seasonal and perennial allergic rhinitis. Allergy to pollens causes the same mechanism of inflammation in response to allergens, which is the result of allergen binding to specific IgE antibody; however, patients with pollen allergy usually complain more of sneezing and runny nose, whereas patients with allergy to perennial allergens more often complain of obstruction, with the episodes of sneezing and runny nose occurring only when exposed to higher concentrations of allergens (house cleaning, around pets). Treatment includes avoidance of allergens, medical treatment and immunotherapy (allergy vaccines, tablets with allergens). Avoidance of allergens means reduction of environmental allergen load to the respiratory system including workplace, which is not easy to accomplish. Medical treatment is usually necessary to control symptoms, and it includes antihistamines, nasal or in tablets, and nasal glucocorticoids (steroids). Antihistamines should be second generation, which do not cause sedation, and such treatment shows more efficacy on runny nose, sneezing and nasal itch than on nasal stuffiness. Nasal steroids are more potent in improving nasal patency than antihistamines, and are at least as potent in the control of all other nasal and ocular symptoms. Nasal patency may be improved by nasal or oral decongestants, but such treatment should be reduced to as short period as possible, since after several days of using nasal decongestants rebound congestion may occur and patients will need nasal decongestants to improve nasal airways even when allergens are not around anymore.

[Infections with respiratory syncytial virus in North Lebanon--prevalence during winter 2008]

Between 1 December 2007 and 31 May 2008, we analysed 120 nasopharyngeal swabs for the presence respiratory syncytial virus (RSV) infection in 120 children aged 15 days to 6 years, hospitalized in 2 hospitals in North Lebanon. Of the 120 samples, 32 were positive (26.7%) for RSV. There was a peak in January which progressively disappeared from February to May. Being positive for RSV was significantly associated with the presence of rhinorrhoea and dyspnoea as clinical symptoms and the absence of pneumonia signs on chest X-ray and the diagnosis of bronchitises or bronchiolitis. Testing for RSV is important in cases of respiratory infections in children as it may limit unnecessary prescription of antibiotics.

Observational study on the performance of the Narhinel method (nasal aspirator and physiological saline solution) versus physiological saline solution in the prevention of recurrences of viral rhinitis and associated complications of the upper respiratory tract infections (URTI), with a special focus on acute rhinosinusitis and acute otitis of the middle ear

AIM

The aim of this study was to assess the validity of Narhinel method in the prevention of recurrences of viral rhinitis and of any associated sequelae, in particular acute otitis of the middle ear (AOM) and acute rhinosinusitis (AR).

METHODS

This was a prospective observational study, in children aged from two months to two years, observed for five months during the cold season and carried out by family pediatricians (FIMP association) in Friuli Venezia Giulia, Italy. The study enrolled 435 patients. The observed population consisted of two groups: the first one of 238 children treated with Narhinel method and the second one of 197 patients treated only with the physiological saline solution. In compliance with the guidelines of an observational trial, the children were prescribed the therapeutic treatments used as a routine. The patients were recruited for the trial after the responsible parent had signed the informed consent form. The study protocol had been approved by the Ethics Committee of the area of Pordenone. In order to be recruited, patients had to comply with the following criteria: symptoms suggestive of the common cold; age > or =2 months < or =2 years; male and female. Patients presenting one or more of the following characteristics were not included: systemic diseases; congenital nasal obstruction (choanal atresia); infections of the upper and lower respiratory tracts other than common cold; systemic and/or topical use of antibiotics and/or corticosteroids at the moment of recruitment. During the five months of the observation period, all the therapies that the investigators had decided it was necessary to administer had been included and recorded in the CRF. Patients evaluations were carried out for five months. The clinical assessment was performed at baseline (B), in the first week (Fw) and monthly and described as M1 to 5; several clinical parameters were analyzed (anterior and posterior rhinorrhoea, oral respiration, noisy nasal respiration, and nasally transmitted thoracic sounds) and measured by the pediatrician at all examinations from B to M5. Other parameters were derived from the parents' daily observations, recorded in a diary and made note of the quality of sleep, diet and respiration, and the use of any drug during any relapse of acute rhinitis (common cold episode). Recurrence of AOM and AR was assessed by the pediatrician at M1-2-3-4-5. Safety of use was determined using the Italian Health Ministry incident/near incident report sheets for Medical Device and based on diaries where the parents took note of any events which occurred during the observation period. Parental satisfaction and compliance were assessed through a questionnaire given to the parents at the end of the last visit (M5).

RESULTS

In the Narhinel group, the mean age was inferior (statistically significant): 8.9 compared to 11.4 months in the physiological saline solution group. The frequency of recurrences from viral rhinitis was very similar in the two groups and a decrease (statistical significant) was observed from M3 through M5 in both groups. Rhinorrhea, oral breathing, and other upper respiratory symptoms, improved in the two groups even if in the Narhinel one the improvement was more prominent during the first two months of observation. There was no difference in the frequency of AR between the groups: at M4 and M5, there was a statistically significant decrease in the frequency of episodes. The frequency of AOM varied in the two groups considering a comparison intra-groups: at M5 the decrease of episodes was statistically significant in the Narhinel group. In Narhinel group, AR and acute AOM seem to be more markedly controlled (frequency) especially for AOM. The frequency of adverse events (AEs) did not vary in the two groups: in the Narhinel one there was a difference (not statistically significant and not clinically relevant) in the number of patients with AEs, especially crying and nasal bleeding. One serious AE was reported in the physiological saline solution group. A 14-month-old child developed laryngospasm which recovered completely after hospital treatment with adrenaline. This event was not related to treatment with saline solution and causality was assessed as "unlikely" by the investigator. In the Narhinel group, one serious event of moderate convulsion febrile in a male patient (age of 0.9) was reported. The causality relationship was assessed by the investigator as improbable. Parents' satisfaction was higher (statistically significant) in the Narhinel group compared to the physiological saline solution alone group.

CONCLUSION

In acute rhinites (common cold) both medical devices are effective nevertheless Narhinel method is valid and shows better results in AOM and AR. Moreover Narhinel method was also more appreciated by parents than physiological saline solution. According to authors' experience, the Narhinel method is safe and its performance is valid in the prevention of AOM and AR in children.

[The role of infection in the development of polypous rhinosinusitis in patients with bronchial asthma]

At present, many authors accept the many-factor theory of development of polypous rhinosinusitis associated with bronchial asthma according to which this condition should be regarded as an inflammatory syndrome in subjects predisposed to a specific tissue reaction. Inflammation induced by an infection is accompanied by the release of protease-inhibiting enzymes that turn inflammation into a chronic process thereby contributing to tissue disintegration, remodeling of mucous membranes, and development of polyps.

Identification of influenza, parainfluenza, adenovirus and respiratory syncytial virus during rhinopharyngitis in a group of Mexican children with asthma and wheezing

BACKGROUND

Viral infections can promote allergic sensitization in genetically susceptible individuals. Besides, they are the main cause of wheezing in children.

OBJECTIVE

To assess the frequency with which influenza, parainfluenza, adenovirus and respiratory syncytial virus (RSV) cause rhinopharyngitis in patients with asthma and wheezing.

PATIENTS AND METHODS

Longitudinal, prospective study in which 168 patients with asthma and wheezing, who attended the outpatient allergy clinic of the National Institute of Pediatrics, Mexico, during the spring (from April through June), with clinical signs and symptoms of rhinopharyngitis were included. Samples of nasal secretions were taken with a long swab, and identification of RSV, adenovirus, infuenza A and B and parainfluenzae 1, 2 and 3 by means of direct immunofluorescence (DI) was carried out.

RESULTS

Samples of nasal secretions were taken in 100 children with asthma and 68 with wheezing, aged 2-17 years. Viral identification was positive in 75% and 44.1% of the patients, respectively. By age group, RSV predominated among children in preschool age; and influenza A among children in school age and adolescents. Influenza A, adenovirus and parinfluenza 3 were identified more frequently in asthmatic children, whereas influenza A and RSV in patients with wheezing. Coinfection of two viruses was found in 17.1% of all patients with positive DI; the most frequent association was parainfluenza 1 and 2.

CONCLUSIONS

Viral identification by means of DI is a fast and non-invasive technique that could favor the early beginning of antiviral treatments in children with asthma and wheezing.

Respiratory syncytial virus rhinosinusitis in intensive care unit patients

This study reported a case of rhinosinusitis for Respiratory Syncytial Virus in Intensive Care Unit patient. The settings were Intensive Care Unit at Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil. One female HIV-infected patient with respiratory failure and circulatory shock due to splenic and renal abscesses, who developed rhinosinusitis caused by RSV and bacteria. Respiratory viruses can play a pathogenic role in airways infection allowing secondary bacterial overgrowth.

[Acute rhinosinusitis in children]

Rhinosinusitis in children is mainly caused by virus. After medical examination and according to the evolution, two clinical situations are defined: sub acute and persisting rhinosinusitis or acute and severe rhinosinusitis. Due to the development of sinus cavities, location of rhinosinusitis varies with age, ethmoïditis being the first location in young child. Imaging is recommended in cases of severe symptomatology or extra maxillary locations or for complications. Antibiotherapy is recommended in severe cases or complications. The choice of drugs is supported by the bacterial epidemiology of these infections and the level of resistance in France of the different microorganisms involved. In other cases, management includes symptomatic treatment and obvious informations on the different modalities of evolution.

Mediators and cytokines in allergic and viral-triggered rhinitis

Intermittent allergic rhinitis and common cold constitute frequent conditions and show similar clinical symptoms. The purpose of this study was to investigate the pattern of cytokines in the nasal fluid of patients with acute symptoms caused by allergic and viral rhinitis. Nasal secretions were analyzed by immunosorbent assay techniques using a cytokine panel assay and routine ELISA. Allergic patients had significantly higher levels of eosinophil cationic protein (ECP), interleukin (IL)-5, and tryptase. Significantly elevated concentrations of proinflammatory cytokines (IL-1b, IL-6, IL-7, IL-17, interferon [IFN] gamma, and tumor necrosis factor [TNF]-alpha) as well as chemokines for cellular infiltration (IL-8, monocyte chemoattractant protein 1, and macrophage inflammatory protein 1beta), factors for cellular proliferation (granulocyte colony-stimulating factor [G-CSF] and granulocyte macrophage colony-stimulating factor [GM-CSF]), and elastase were found in viral rhinitis. IL-10 was only detectable in viral rhinitis. IL-4 was significantly higher in patients with viral rhinitis than allergic rhinitis, and IL-5 was significantly elevated in viral rhinitis compared with controls. In viral-triggered rhinitis, we detected a predominantly Th1-type cytokine pattern with potent proinflammatory mediators. Factors reflecting a neutrophil and eosinophil immune response, due to IL-5, IL-8, GM-CSF, ECP, and elastase were shown. Nasal secretions of patients with allergic rhinitis showed highest concentrations of tryptase, IL-5, and ECP, reflecting a mast cell and eosinophil immune response. Nasal secretion levels of IL-4 did not show highest levels in allergic rhinitis but did in viral rhinitis. IL-4 also may play a role in limiting inflammatory processes by inhibiting the production of inflammatory cytokines.

Identification of viruses in patients with postviral olfactory dysfunction

Objective: Causative viruses of postviral olfactory dysfunction (PVOD) have not yet been identified. The aim of this study was to investigate causative viruses in patients with PVOD.

Study Design and Methods: Nasal discharge was collected from 24 patients with PVOD. We investigated the presence of 10 viruses in nasal discharge and examined the time course, with regard to changes in olfactory dysfunction and nasal obstruction in patients with PVOD, using questionnaires, acoustic rhinometry, and olfactory tests.

Results: Rhinoviruses were detected in 10 patients by electrophoresis. Rhinoviruses were also confirmed in four patients by nucleotide sequences. Viral serotypes were identified to be human rhinovirus (HRV)‐40, HRV‐75, HRV‐78, and HRV‐80. One of the four patients complained of anosmia, whereas another complained of dysosmia. Olfactory testing did not show significant improvement at 4, 8, 11, and 24 weeks after the first visit in the four patients, although results of acoustic rhinometry significantly improved. Two of the four patients complained of olfactory dysfunction even 6 months after the first visit. Coronavirus and parainfluenza virus were detected in one patient each, and Epstein‐Barr viruses were detected in three patients.

Conclusions: This study for the first time detected rhinovirus, coronavirus, parainfluenza virus, and Epstein‐Barr virus in nasal discharge of patients with PVOD. Furthermore, the present study suggests that rhinoviruses can cause olfactory dysfunction through mechanisms other than nasal obstruction and that rhinoviruses can induce various severities and different time courses of olfactory dysfunction.

Role of viruses and atypical bacteria in asthma exacerbations among children in Oporto (Portugal)

BACKGROUND

Upper respiratory tract infections are known to be a significant precipitant of acute asthma exacerbations. The aim of this study was to evaluate seasonal trends and the role of these pathogens in asthma exacerbations in school-aged children from Oporto (Portugal).

METHODS

Nasal aspirates were collected from children aged 6 to 12 years old with asthma exacerbations attended in the Pediatric Emergency Department one day per week from January 1 to December 31, 2003. Demographic data, severity of asthma and asthma exacerbations, and current treatment were recorded. Samples were obtained through nasal wash with 1 ml saline and were processed by immunofluorescence assays (respiratory syncytial virus, adenovirus, parainfluenza and influenza virus), retrotranscription polymerase chain reaction (rhinovirus) and polymerase chain reaction (enterovirus, Chlamydia pneumoniae and Mycoplasma pneumoniae).

RESULTS

In 54 eligible children, 37 nasal samples were obtained. Infectious agents were detected in 78 % of the patients. Rhinovirus was detected in 70.3 %, Mycoplasma pneumoniae in 16.2 %, enterovirus in 10.8 %, and Chlamydia pneumoniae in 2.7 %. Coinfection was identified in 21.6 % of the samples. There was no significant correlation between current treatment status, severity of asthma or exacerbations and the isolated agents. Two distinct peaks of asthma exacerbation were found, 40.5 % in spring and 32.4 % in autumn [corrected] The highest number of cases was recorded in March and the lowest in August and January. Rhinoviruses was detected in 27 % of the cases in autumn and in 24.3 % in spring [corrected]

CONCLUSIONS

These results confirm the previously reported high frequency of rhinovirus detection in asthma exacerbations in children and provide evidence that asthma exacerbations and rhinovirus infections follow a seasonal pattern, occurring mostly in spring and autumn. The findings also underscore the frequency of Mycoplasma pneumoniae detection, and emphasize the importance of this agent as a possible trigger of asthma exacerbations.

Formerly unclassified, acid-stable equine picornaviruses are a third equine rhinitis B virus serotype in the genus Erbovirus

Acid-stable equine picornaviruses (ASPs) were identified as a distinct serotype of equine picornaviruses that were isolated from nasal swabs taken from horses with acute febrile respiratory disease in the UK and Japan, and were placed in the group of unclassified picornaviruses. The nucleotide sequence of the P1 region, encoding the capsid proteins, was determined for three ASP isolates from the UK and the sequences were aligned with published sequences of Equine rhinitis B virus (ERBV), genus Erbovirus, including acid-labile ERBV1 and ERBV2 and the recently identified acid-stable ERBV1. The ASPs belong to the same phylogenetic group, composed of five acid-stable ERBV1 isolates. ERBV1 rabbit antiserum neutralized the ASP isolates at approximately 1/10 titre relative to acid-stable and acid-labile ERBV1 isolates, supporting prior findings that ASPs are a distinct serotype, albeit cross-neutralizing weakly with ERBV1. The genus Erbovirus therefore presently comprises three serotypes: ERBV1, ERBV2 and the proposed ERBV3.

Persistent inflammation and hyperresponsiveness following viral rhinosinusitis

OBJECTIVES

To develop a murine model of viral rhinosinusitis.

STUDY DESIGN

Randomized, controlled, animal model.

METHODS

Mice were intranasally inoculated with Sendai virus (SeV) or ultraviolet (UV)-inactivated virus. On days 3 and 10 postinfection, nasal lavage fluid was obtained for viral culture. On days 4, 10, and 38 postinfection, sinus mucosa was harvested and analyzed by flow cytometry for CD3-, CD4-, CD8-, CD25-, CD11b-, CCR3-, and GR1-positive cells. Nasal hyperresponsiveness to histamine challenge was measured on days 8 and 36 postinoculation.

RESULTS

On day 3, viral cultures were positive from all SeV-inoculated mice but from none of the UV-inactivated mice (P<or=.0039). There was no growth of virus from either group on day 10. On day 4, flow cytometry on SeV-infected sinus cells showed a significant increase in macrophages (P<or=.03) and neutrophils (P<or=.02) compared with controls. This inflammation resolved by day 10. On day 38, mice inoculated with SeV had significantly more CD8+ (P<or=.044) and CD4+CD25+ (P<or=.017) cells than did controls. On day 8, there was a significant increase in both sneezing (P<or=.002) and nasal rubbing (P<or=.002) in the SeV-infected group to histamine challenge compared with controls. This difference continued to day 36.

CONCLUSIONS

Inoculation with SeV results in an acute infection that resolves spontaneously within 10 days. Infected mice develop a significant increase in T-suppressor and T-regulatory cells after resolution of the acute infection, which persists for at least 38 days. The persistence of these T cells is associated with hyperresponsiveness to histamine. This mouse model has some parallels to chronic rhinosinusitis after a viral infection in humans and should allow us to clarify the pathophysiology of this disease.

Beginning Antibiotics for Acute Rhinosinusitis and Choosing the Right Treatment

Acute bacterial sinusitis (ABS) is an extremely common problem in both children and adults. There are three clinical presentations of acute sinusitis: (1) onset with persistent symptoms (nasal symptoms or cough or both for > 10 but < 30 d without evidence of improvement); (2) onset with severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days); and (3) onset with worsening symptoms (respiratory symptoms, with or without fever, which worsen after several days of improvement). Images to confirm the presence of acute sinusitis are necessary in older children (> 6 years) and adults to enhance the certainty of diagnosis. The predominant bacterial species that are implicated in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis in children. In the last decade, there has been an increasing prevalence of penicillin-resistant S. pneumoniae, and beta-lactamase-producing H. influenzae and M. catarrhalis. Although there has been some controversy in the literature regarding the effectiveness of antibiotics in the treatment of ABS, most studies in which the diagnosis of acute bacterial sinusitis is confirmed with images and appropriate anti-biotics are prescribed show superior outcomes in recipients of antibiotics. Therapy may be initiated with high-dose amoxicillin or amoxicillin-clavulanate. In penicillin-allergic patients or those who are unresponsive to amoxicillin, amoxicillin-clavulanate is appropriate. Alternatives include cefuroxime, cefpodoxime, or cefdinir. In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed. The optimal duration of therapy is unknown. Some recommend treatment until the patient becomes free of symptoms and then for an additional 7 d.

Efficacité de Dérinox® chez des patients souffrant d’une rhinite virale évaluée par un PNIF (Peak Nasal Inspiratory Flow)

OBJECTIVES

The aim of this study was to compare the efficacy and tolerance of Dérinox (D) to Rhinofluimucil (R) and placebo (P) in the treatment of common cold, using an objective measure of nasal obstruction, the Peak Nasal Inspiratory Flow (PNIF--Clement Clarke International, Harlow, Angleterre).

PATIENTS AND METHODS

This randomized, double-blind, double-dummy, parallel group study enrolled 354 patients (34 P, 165 D et 155 R) included by 85 general practitioners. The treatment duration was 5 days at usual recommended dosage regimens. PNIF measures were done before drug administration (T0) as well as 15 min and 3 h after each intake. Moreover, nasal obstruction, rhinorrhea and global discomfort were subjectively assessed.

RESULTS

The efficacy of D was superior to that of P and R when comparing PNIF from T0 to T3 h after the first intake. At T15 min, rhinorrhea was significantly improved with both active treatments and global discomfort was significantly improved with D only. Treatment tolerance was satisfactory and comparable between the 3 groups.

CONCLUSION

Efficacy of Dérinox(R) was superior to that of P and R for the improvement of the nasal obstruction (PNIF) between T0 and T3h (main criteria) after the first intake in patients suffering from common cold.

Atomized nasal douche vs nasal lavage in acute viral rhinitis

OBJECTIVE

To evaluate the efficacy of the atomized nasal douche in the restoration of physiological nasal functions in patients affected by acute viral rhinosinusitis, when compared with nasal lavages with isotonic sodium chloride solution.

DESIGN

Randomized clinical trial.

SETTING

The ENT Department at the University of Siena Medical School.

PATIENTS

Two hundred patients affected by acute viral rhinosinusitis were included in the study.

INTERVENTIONS

Patients were randomly divided into 2 groups: group 1 patients received an atomized nasal douche, and group 2 patients received nasal lavages with isotonic sodium chloride solution. Patients underwent treatments 4 times per day for 15 days in our institution under our direct control.

RESULTS

Atomized nasal douches significantly improved inspiratory and expiratory rhinomanometric resistance (P<.01) and nasal volumes measured by acoustic rhinometry (P<.001). Nasal lavages were unable to modify these variables significantly (P<.3). Only atomized nasal douches were able to normalize mucociliary transport time to a physiological level (P<.001).

CONCLUSIONS

The atomized nasal douche demonstrated a better efficacy than traditional nasal lavages with isotonic sodium chloride solution in restoring all the physiological nasal functions. For this reason, and considering ease of use, painlessness, cheapness, and manageability of the instrument, we suggest the use of the compressor-micronizer chamber system (Rinoflow Nasal Wash & Sinus System) as a routine adjuvant to every treatment of acute rhinopathies.

Assessment of infectious organisms associated with chronic rhinosinusitis in cats

OBJECTIVE

To determine detection rates for feline herpesvirus type 1 (FHV-1), Mycoplasma spp, fungi, and bacteria in flush samples and biopsy specimens from the nasal cavities of cats with and without chronic rhinosinusitis (CRS).

DESIGN

Prospective study.

ANIMALS

10 CRS-affected cats and 7 cats without signs of respiratory tract disease.

PROCEDURES

Nasal flush samples and biopsy specimens were collected from all cats for bacterial (aerobic and anaerobic), fungal, and mycoplasmal cultures; additional biopsy specimens were collected for virus isolation and polymerase chain reaction (PCR) assay (to detect FHV-1 DNA).

RESULTS

Aerobic bacteria were detected in flush samples from 5 of 7 control cats; culture of flush samples from CRS-affected cats yielded aerobic bacteria (9/10 cats), anaerobic bacteria (3/10), and Mycoplasma spp (2/10). No fungal organisms were isolated from any cat. Potential pathogens were isolated significantly more often from CRS-affected cats than from control cats. Bacterial culture of biopsy specimens yielded aerobic bacteria (2/7 control cats and 4/10 CRS-affected cats) and anaerobic bacteria (2/10 CRS-affected cats). Although FHV-1 was not detected in nasal biopsy specimens from control or CRS-affected cats, FHV-1 DNA was detected via PCR assay in specimens from 4 of 7 control cats and 3 of 10 CRS-affected cats.

CONCLUSIONS AND CLINICAL RELEVANCE

Compared with findings in control cats, anaerobic bacteria, Mycoplasma spp, and a variety of potentially pathogenic organisms were detected more commonly in samples from cats with CRS. In both groups, FHV-1 was detected via PCR assay as a nonviable organism or in noncultivable amounts.

Feline herpesvirus type-1 transcription is associated with increased nasal cytokine gene transcription in cats

The etiopathogenesis of chronic nasal discharge in the cat is poorly understood. The objective of this study was to investigate alterations in transcription of genes for cytokines and chemokines in association with feline herpesvirus-1 (FHV-1) mRNA transcription. Nasal samples from 21 cats were submitted for FHV-1 virus isolation (VI), traditional endpoint polymerase chain reaction (PCR) detection of FHV-1 DNA, and quantitative real-time TaqMan PCR analysis of cytokines and chemokines (interleukin [IL]-4, IL-5, IL-6, IL-10, IL-12p40, IL-16, IL-18, interferon [IFN]-gamma, tumor necrosis factor [TNF]-alpha, and regulated on activation normal T cell expressed and secreted protein [RANTES]) and of FHV-1 mRNA and DNA. Co-infection with feline calicivirus or Chlamydophila spp. was excluded in all cats. Gene transcription in nasal samples from four specific pathogen free (SPF) cats served as the calibrator for cytokines. FHV-1 was detected by VI in 14 of 21 samples, by traditional PCR in 18 of 21 samples, and by quantitative PCR in 13 (mRNA+) and 18 (DNA+) samples. Nasal samples from cats positive for FHV-1 mRNA displayed significantly increased transcription of IL-6, IL-10, IL-12p40, IL-18, IFN-gamma, TNF-alpha, and RANTES (P<0.05) in comparison to samples from cats negative for FHV-1 mRNA. The cycle threshold for FHV-1 DNA was significantly higher in cats with detectable FHV-1 mRNA (P<0.05). Increased transcription of cytokines/chemokines in cats with detectable mRNA for FHV-1 suggests a role for FHV-1 in nasal inflammation.

[Viral diseases as a predisposing factor of developing secondary oto- and rhinogenic bacterial meningitis]

Effects of viruses and bacterial associations are suggested to promote secondary purulent intracranial complications in ENT patients. Fundamental aspects of pathogenesis of viral neuroinfections and pathogenetic mechanisms of different conditions provoked by viral factors promoting bacterial complications are presented. Hemoculture, and cerebrospinal fluid in 24 patients with secondary purulent rhinogenic and otogenic meningitis were studied with polymerase chain reaction for enteroviruses, cytomegaloviruses, Epstein-Barr, herpes, zoster viruses. The viruses were present in the studied media in 29.4% samples.

Experimental transmission of a herpesvirus in Greek tortoises (Testudo graeca)

An experimental transmission study aimed at fulfilling Koch's postulates for a herpesvirus-associated stomatitis-rhinitis in Mediterranean tortoises is presented. Clinical, pathologic, serologic, and molecular studies were performed linking tortoise herpesvirus with the pathogenesis of stomatitis-rhinitis. Four adult Greek tortoises received either intranasally or intramuscularly two tortoise herpesvirus isolates by primary experimental infection and secondary challenge 11 months later. After the primary experimental infection and the secondary challenge, clinical signs of illness developed, which included conjunctivitis, diphtheritic oral plaques, and oral discharge. At 4 weeks after the secondary challenge, all tortoises were humanely euthanatized and evaluated. Although neutralizing antibodies developed after the primary experimental infection, they apparently did not prevent the later development of recurrent clinical signs. Polymerase chain reaction (PCR) and reverse transcription-PCR analyses allowed sensitive characterization of the systemic distribution of the herpesvirus DNA sequences and their presence in the cranial nerves and brains of the infected tortoises. Despite the failure to recover the herpesviruses used in the transmission study, the findings support the premise that tortoise herpes-virus is a primary pathogen of Greek tortoises.

Chronic rhinosinusitis in young children differs from adults: a histopathology study

OBJECTIVE

A histopathologic study of children with chronic rhinosinusitis (CRS) was undertaken to compare the sinus mucosa in pediatric and adult CRS.

STUDY DESIGN

CRS has been defined as persistent or recurrent sinusitis symptoms for >or=12 weeks despite conventional medical therapy, with abnormal computed tomography of the maxillary sinuses. Maxillary mucosal biopsies were obtained from pediatric CRS subjects for inflammatory cell and morphologic studies. Archival sinus mucosal tissues from adults with CRS were used as histologic controls. Sinus lavages were performed on children with and without CRS for microbiologic studies.

RESULTS

Sinus mucosal biopsies were obtained from 19 children with CRS (median age, 3.0 years; range 1.4-8.2 years). Pediatric CRS biopsies, as compared with adult CRS controls, had a higher density of submucosal lymphocytes (median 469 versus 294 cells/mm(2) per 5 high-power fields [HPF]; P=.02), lower density of submucosal eosinophils (medians 13 versus 82 cells/mm(2) per 5 HPF; P=.01), thinner and more intact epithelium (P=.01 and.07, respectively), thinner basement membranes (P=.002), and fewer submucosal mucous glands (P=.004).

CONCLUSION

The sinus mucosa of young children with CRS has less eosinophilic inflammation, basement membrane thickening, and mucus gland hyperplasia characteristic of adult CRS.

Respiratory consequences of rhinovirus infection

Rhinoviruses, a genus of the family Picornaviridae, are the cause of more than 50% of respiratory tract infections. Complications of rhinovirus infections, which include otitis media, sinusitis, exacerbations of asthma, and other pulmonary diseases, can be significant in certain populations. Reverse transcriptase-polymerase chain reaction has allowed the identification of rhinoviruses and led to a greater appreciation of the role of this pathogen in upper and lower respiratory tract disease. Furthermore, antiviral agents with broad activity against rhinoviruses have recently been developed, have undergone clinical trials, but have not been approved for clinical use. By altering the clinical course of picornavirus infections, it may be possible to minimize their potential adverse consequences.

[Influenza in the pediatric hospital unit at Antananarivo]

62 rhinopharingeal samples from malagasy children, aged of 6 days to 14 years old, hospitalized because of acute respiratory infections, with doubtful viral etiology case, during June to August 1992, at the "Hôpital des Enfants" in Antananarivo, were examined by two methods: inoculation by embryonned eggs and inoculation by MDCK cells. 24.1% of the samples were positive. The repartition of the cases by age and by sex were studied. The children aged of 1 to 12 months were the most affected with 65.7% of all cases (male: 60%, female: 40%). One subtype was detected: A(H3N2).

Cytomegalovirus infection in a pig in South Africa

An 8-week-old piglet with dyspnoea, bilateral mucopurulent nasal discharge and mouth breathing was euthanased and a necropsy was performed. Apart from histological evidence of diffuse rhinitis, large intranuclear inclusion bodies, pathognomonic forporcine cytomegalovirus infection, were detected within mucous glands on the nasal turbinates. This is the first such case to be diagnosed in South Africa.

Virus-provoked rhinitis in patients who have allergies

The most common illnesses in humans are the respiratory tract infections caused by viruses. When limited to the upper respiratory region, these infections often are designated as "a common cold." Viruses commonly associated with these upper respiratory infections (URI) include rhinoviruses (RVs), respiratory syncytial virus, influenza virus, parainfluenza virus, corona virus, and adenoviruses. Clinical observations have suggested that patients with allergic rhinitis and asthma experience more pronounced symptoms during a viral URI than patients who do not have allergies and who are infected with the same virus under similar circumstances. Using an experimental virus infection model in human volunteers with and without allergic rhinitis, several groups of clinical investigators have studied the effects of experimental RV infections. These observations indicate that the experimental virus infection may induce host responses that provoke enhanced immunoglobulin E (IgE) synthesis. Whether this translates into enhanced symptoms has been suggested in one study but not in another. This article will review these studies, which suggest that it is the host response to the virus and not the virus itself that plays the major role in symptom pathogenesis.

Histologic and immunologic observations of viral-induced rhinosinusitis in the mouse

Viral upper respiratory infection is one of the most common diagnoses made in primary care offices. Although symptoms resolve within 1 week for many patients, a percentage develops rhinosinusitis, and many of these patients are treated with antibiotics. We have developed a model of viral rhinosinusitis using intranasal inoculation of reovirus into mice that were then killed on postinoculation days 2, 4, 7, 10, 14, or 21 and heads were embedded in paraffin for histological and immunohistochemical analyses. Reovirus-like immunoreactivity was noted in the septa and paranasal sinus mucosa in mice as early as day 2, with peak intensity seen on day 4, and scant staining seen on day 7. Complete absence of viral staining was seen by day 10, which corresponded with increased intracellular adhesion molecule 1 immunostaining in the nose. By day 10, a large mucosal influx of B cells was observed, with a moderate influx of macrophages and smaller influx of T cells. By day 14, there was a peak in the number of B cells with a corresponding, but less pronounced peak in T cells, while macrophages began to decline at this point. By day 21, the panel of immune markers returned to near normal levels. The results of this study suggest that the immune system continues to produce a response as long as 2 weeks after clearance of viral antigens. One proposed mechanism for this phenomenon is that local factors such as cytokines are released continually after infection, even in the absence of persistent viruses or bacteria.

Viral rhinitis

Viral rhinitis is a common, morbid, and costly malady, often complicated by otitis media, sinusitis, and asthma. Current therapies are relatively ineffective and aimed at reducing symptoms rather than moderating underlying mechanisms. Nasal elevations of proinflammatory cytokines track symptom expression during viral rhinitis, and it is hypothesized that these chemicals orchestrate a common response to infection with many different viruses that cause rhinitis. Also, recent evidence supports a role for neurogenic inflammation in the development of complications. Future studies should dissect the role of proinflammatory cytokines and neuropeptides in the expression of symptoms, signs, pathophysiologies, and complications of viral rhinitis.

Detection of chelonid herpesvirus DNA by nonradioactive in situ hybridization in tissues from tortoises suffering from stomatitis-rhinitis complex in Europe and North America

Chelonid herpesvirus (ChHV) infection in tortoises associated with stomatitis-rhinitis complex is a severe, mostly epizootic disease characterized by proliferative and diphtheroid-necrotizing glossitis, pharyngitis, rhinitis, and tracheitis, often occurring with pneumonia and encephalitis. The UL5 gene from a German ChHV isolate was used to generate a digoxigenin-labeled 307-base-pair DNA probe by polymerase chain reaction (PCR). ChHV DNA was detected in paraffin-embedded tissues of five naturally infected tortoises (two Afghan tortoises [Testudo horsfieldii], USA; two Hermann's tortoises [Testudo hermanni], Switzerland; one T. hermanni, Germany) by means of in situ hybridization (ISH) and PCR. Distribution of ChHV DNA exhibits many characteristics of alphaherpesvirus but also some characteristics of betaherpesvirus infections. The amino acid sequence of a portion of the ChHV UL5 homolog exhibited more than 50% similarity to alphaherpesvirus UL5 proteins. Nuclear hybridization signals were detected in epithelial cells of the lingual mucosa and glands. Furthermore, ChHV DNA was observed in tracheal epithelium, pneumocytes, hepatocytes, the renal tubular epithelium, cerebral glia cells and neurons, and intramural intestinal ganglia. ChHV DNA in endothelial cells of many organs underlines the systemic character of the disease. Importantly, ChHV DNA was detected by ISH in multiple tissues of tortoises originating from different geographic provenances. This indicates a high degree of conservation of the UL5 gene fragment among viruses prevalent in tortoises on different continents. With the described ISH, a molecular biological tool is available for rapid and specific diagnosis of ChHV infections and, more importantly, comparative pathogenetic studies of ChHV isolates from geographically unrelated regions.

PCR assay for detecting porcine cytomegalovirus

This is the first published report of a PCR assay for detecting porcine cytomegalovirus (PCMV), the causative agent of inclusion body rhinitis in pigs. The DNA to be tested was extracted directly from lungs and nasal scrapings of pigs with various clinical syndromes. Fifty-nine percent (74 of 126) of tested pigs with various clinical syndromes were found to be PCR positive for PCMV. It is hoped that veterinary diagnostic laboratories will benefit by using this PCR assay for routine testing and surveillance of PCMV in pigs.

Electrophysiology and pathology evaluation of the Yucatan pig as a non-rodent animal model for regulatory and mechanistic toxicology studies

Six male and six female Yucatan pigs were utilized to investigate the feasibility of this species as a non-rodent model for routine regulatory and mechanistic toxicology studies. This study evaluated disease surveillance and computerized electrophysiology, along with possible gross and micropathology changes. Two pigs were used as sentinel animals to evaluate the microbiological status of the vendor upon arrival; the other pigs were maintained as biomonitors and to provide baseline clinical chemistry, urinalysis, pathology and electrophysiology data. The electrophysiology tests conducted included electrocardiography (ECG), electroretinography (ERG) and quantitative electroencephalography (qEEG), which achieved consistent baseline values with acceptable intrasubject variation. Tissue cholinesterase and histochemical staining were done to determine their suitability for testing cholinesterase compounds. Evaluation of the serum chemistry profile demonstrated increased CPK and LDH, which was likely associated with slight haemolysis or minor subclinical muscle stress during handling. There were no additional clinical chemistry changes or findings in haematology, urinalysis parameters or gross pathology. Micropathology found an absence of background lesions which would interfere with routine toxicology studies, except for a mild rhinitis. The aetiological agent was identified by electron microscopy as being consistent with inclusion body rhinitis of swine, previously unreported in miniature swine. This would most notably interfere with inhalation studies. The anatomical and physiological similarities of the Yucatan pig, along with its ability to accept the performance of electrophysiology tests allow this species to be considered as a suitable model for organ system testing in toxicology studies.

Rhinosinusitis and atopy in patients infected with HIV

HYPOTHESIS

Rhinosinusitis is common during HIV infection; its prevalence is uncertain and could probably be related to clinical features, immunoallergological status, and diagnostic criteria

METHODS

Seventy-four patients hospitalized with HIV infection were prospectively evaluated for the presence of rhinosinusitis based on clinical findings, nasal endoscopy, or paranasal sinus computed tomography (CT). Immune status, nasal smear, features of atopy (based on the prick test), and its contribution to sinusal inflammatory pathology were also evaluated.

RESULTS

Most patients were severely immunosuppressed: CD4+ 155+/-201 cells/mL and 12+/-11% (mean +/- SD). Thirty-five percent of the patients presented at least two criteria of rhinosinusitis (clinical findings, nasal endoscopy, and CT: 35%; clinical findings and CT: 50%; nasal endoscopy and CT: 15%). CT scan showed multiple sinus involvement, opacification over 25% of the total volume of the maxillary sinus in 50% of patients, and opacification of the sphenoidal sinus in 40% of cases. Atopy was present in 18% of patients, a figure which reflects the expected prevalence in our geographic area. Two independent predictors were associated with a higher probability of rhinosinusitis: bilateral absence of maxillary infundibular patency (odds ratio, 7.5; 95% CI = 2.03-27.9) and low total count (odds ratio, 0.99; 95% CI = 0.99-1.00) or percentage of CD4+ (odds ratio, 0.93; 95% CI = 0.88-1.00).

CONCLUSIONS

There is a high prevalence of rhinosinusitis in HIV-infected individuals. This finding is related to a decreased cellular immunity, but it does not appear to be related to IgE-related immediate hypersensitivity. Nasal endoscopy should be the first-step diagnostic test. However, when clinical suspicion exists and endoscopy fails to explain symptoms, CT scan is a valuable adjunct to establish this diagnosis.

Microbiology of chronic sinusitis

Much controversy still exists about the role of viruses, bacteria and fungi in sinusitis. Until recently, it was not really known that the sinuses take part in the infectious process of a common cold (viral rhinitis). Indeed, CT scans show that in the vast majority of otherwise healthy volunteers with a common cold, and without a previous history of recurrent or chronic sinusitis, the sinuses are involved too. A viral rhinitis alone, however, does not seem to be able to elicit a "clinical" acute sinusitis. Bacteria determine the clinical picture and outcome of sinusitis. There is not much controversy about the role of bacteria in acute sinusitis, S. pneumoniae, H. influenzae and M. catarrhalis being the most frequently involved bacteria. Much more conflicting reports are published about the normal flora of the sinuses, the role of anaerobes and the microbiology of chronic sinusitis. In this chapter the defense and pathophysiologic mechanisms of viral, bacterial and fungal infection of the nasal and sinusal mucosa are described. It is postulated that, although bacteria are very important in acute sinusitis, their role in chronic sinusitis is minimal, the bacteria being opportunistic colonisers.