ALOK SINHADepartment of Medicine

Manipal College of Medical SciencesPokhara, Nepal

UPPER RESPIRATORY TRACT INFECTIONS

• The upper respiratory tract includes • nose• paranasal sinuses• pharynx• upper part of the larynx above the level of the

true vocal cords

Infections of the Upper Respiratory TractSite Disease AgentsNasal cavity Coryza (common cold) Many different viruses

Chronic atrophic rhinitis Bacteria (Klebsiella ozaenae) Rhinoscleroma Klebsiella rhinoscleromatis Invasive fungal infections Mucor, Aspergillus Nasal diphtheria Corynebacterium diphtheriae Mucocutaneous leishmaniasis Leishmania braziliensis Syphilis (tertiary) Treponema pallidum Lepromatous leprosy Mycobacterium leprae Rhinosporidiosis Rhinosporidium seeberi 

Paranasal sinusesAcute sinusitis Pyogenic bacteriaChronic sinusitis Pyogenic bacteriaAspergilloma ("fungus ball") Aspergillus species 

Pharynx, tonsil Acute pharyngitis Many different viruses  Streptococcus pyogenes 

Diphtheria Corynebacterium diphtheriae Pharyngeal gonorrhea Neisseria gonorrhoeae Peritonsillar abscess (quinsy) Pyogenic bacteriaInfectious mononucleosis Epstein–Barr virus

Retropharyngeal space Abscess Pyogenic bacteriaTuberculosis Mycobacterium tuberculosis 

Larynx Acute laryngitis Many different virusesAcute epiglottitis and laryngitis Haemophilus influenzae 

Which specialty should treat & there for teach

these diseases?

.

.

The Common Cold

CORYZA

An estimated 2 of every 5 persons are affected each year (40%)

World population: 6,775,235,741 40% of this = 2,710,094,296

Some experience multiple episodes in 1 year

Rhinoviruses: most common agents Over 100 serotypes have been implicated

Other viruses implicated included coronaviruses influenza C parainfluenza virus adenoviruses respiratory syncytial virus

• Highly contagious: 75% of patients infected with Rhinovirus will have symptoms

• Respiratory droplets spread by sneezing, coughing hand contact with

nose, eyes, or face Fomite - Skin cells, hair, clothing (hanky) bedding

Contributing factors: Change in weatherLoss of sleepGoing outside with wet hairFatigue

Signs and symptoms Incubation period: 2 – 4 days

May last from 6 – 10 days or possibly up to 3 weeks after incubation period

• Initial complaints • sneezing • clear, watery rhinorrhea

@ nasal obstruction • general malaise but no fever

• Subsequently• Headache• nasal congestion• scratchy throat

After 2 – 3 days• nasal discharge becomes thicker, cloudy,

and yellowish in color • systemic symptoms improve• Hoarseness, cough, and sore

throat may last up to 7 – 10 days

Diagnosis: Made on clinical grounds

• Pt’s symptoms• nasal exam showing

reddened, edematous mucosa narrowed nasal passages watery discharge

Laboratory and/or imaging only indicated if other conditions are strongly suspected

Viral isolation/culture is not practical

Treatment

No curative treatment Supportive therapy – 10 treatment

• Rest• Fluids & humidification• Decongestants (Phenylephrine - α1-adrenergic receptor

agonist)

• Analgesics• Cough suppressants• Mucolytics• Antihistamines

Short term use of zinc lozenges (zinc gluconate 10-15 mg q 2 hrs) shown to reduce duration of subjective symptoms if begun early in course of disease

Zinc Gluconate

Role of antibiotics

Antibiotics should be considered if symptoms last longer than 10-14 days (secondary bacterial infection)

Inappropriate prescribing of antibiotics is common• Due to patient beliefs/misinformation of

cold being bacterial in origin

?

PharyngitisPharyngitis

May be of bacterial or viral origin Most common cause Rhinovirus

• Self-limiting; usually lasts 3-4 days Group A, beta-hemolytic strep is

the primary bacterial pathogen

in 1/3 cases - early detection reduces incidence of

Signs and symptoms: Inflammation of pharynx & lymphoid

tissue results in • Fever & malaise • sore throat• rhinorrhea • Tonsillar exudates

• Anterior cervical adenopathy There is usually a lack of cough

Diagnosis On PE: observe throat for tonsillar

exudates; obtain throat swab Rapid streptococcal identification tests

are most commonly used • Sensitivity – 80% • Specificity – 95%

Throat cultures may be collected if rapid strep screen is negative

Management/Treatment: Symptomatic treatment

• salt-water gargles • throat lozenges • Acetaminophen• cool-mist humidification

Antibiotics treatment necessary to treat proven strep infections• Benzathine penicillin G 1.2 million units as a

single dose, is optimal therapy• For pen – allergic pts,

erythromycin 500mg po QID x 10 days Azithromycin 500mg once daily x 3 days

Acute epiglottitis Acute epiglottitis

Bacterial cellulitis of the epiglottis (supraglottis) and/or surrounding tissue

Caused by:• Haemophilus influenzae type b (HiB)- most

likely • H. parainfluenzae and streptococci some times

Average age of onset: 1–5 years old• In most adults the disease is less severe and

of slower onset

Clinical Features Sudden onset of

• Sore throat• Fever• Head forwardly extended, usually with

drooling Stridor - present

Pharyngeal visualization (w/ EXTREME caution) shows a ‘Cherry red' epiglottis

Neutrophil leucocytosis Epiglottis culture usually (+) for HIB

• result takes long time Blood cultures frequently (+) for HIB in children

• organisms fewer than in meningitis Lateral X-Ray neck-

• enlarged hypopharynx • forward neck extension

• with “thumbprinting” of epiglottitis

Epiglottitis- Differential diagnosis

Angioneuropathic edema of supraglottic structures

Anaphylaxis Caustic ingestion Thermal burns of epiglottis Infectious mononucleosis Laryngotracheitis Blunt Trauma

Treatment

• Intubation is often required, but usually discontinued in less than 24h

• Early antibiotic treatment and intubation may

prevent the need for tracheostomy

• Steroids to reduce inflammation and avert tracheostomy- unproven but used

• Tracheostomy: may be required in life threatening conditions

Drug treatment• #1 Ceftriaxone

(or cefotaxime, cefuroxime)

• Others - Ampicillin and Sulbactam• Ticarcillin disodium and clavulanate potassium • piperacillin/tazobactam • levaquin • Gatifloxacin

• Amoxicillin should not be used due to noted resistance

Prevention

HiB vaccination early!!!• Prior to HiB, there were roughly 20 K cases

of HiB disease each year (U S data)

• Post-vaccine era = incidence has decreased by 95%.

Prophylaxix: Family Members, day-care workers,

health-care workers • Rifampin 300 mg q12h x 2d

Acute laryngitisAcute laryngitis

Healthy Vocal Cords Healthy vocal

cords have smooth straight edges

Normal healthy vocal cords • pearly-white color • in contrast to thepinkish surrounding tissue

Causes

Viral (70-80%)

Group A beta-haemolytic streptococcus (20-30%)

Often a complication of acute coryza

• Dry sore throat • Hoarse voice or loss of voice• Attempts to speak cause pain• Initially painful and unproductive cough • Stridor in children (croup) because of

inflammatory oedema leading to partial obstruction of a small larynx

Croup (Laryngotracheobronchitis) is a group of respiratory diseases that often affects infants and children[

Complications rare Chronic laryngitis• Downward spread of infection may cause

• Tracheitis• Bronchitis • Pneumonia

Treatment Rest voice Paracetamol 0.5-1 g 4-6-hourly for relief

of discomfort and pyrexia Steam inhalations may be of value Antibiotics not necessary in simple acute

laryngitis

Influenza Influenza

First recorded pandemic in 1580

Possible accounts in 412 BC

Destroyed Charlemagne's army in 876 A.D.

Killed thousands in 1647

Flu

21 million people died worldwide out of a billion infected (total world population at that time 1.8 billion)

Possible end to war

1918-1919 Spanish Flu pandemic

8.5 million people died in World War I

2009 (H1N1) flu pandemic dataArea Confirmed

deaths

Worldwide (total) 14,286European Union and EFTA 2,290

Other European countriesand Central Asia

457

Mediterranean and Middle East 1,450

Africa 116

North America 3,642

Central America and Caribbean 237

South America 3,190

Northeast Asia and South Asia 2,294

Southeast Asia 393

Australia and Pacific 217

Note: The proportion of confirmed deaths within total deaths due toA/H1N1 is unknown

Swine Flue (H1N1)Swine Flue (H1N1 Influenza)

Answer these two questions Is the Influenza or Flu caused by

“Influenza” virus What H. Influenza is

?

Etiology

• caused by a group of myxoviruses- • common types

• A

• B• C

Influenza A (H1N1) virus is a subtype. causes • endemic in pigs – swine influenza • and birds – avian influenza new H1N1 strain of swine-origin caused pandemic

• New influenza viruses are constantly being produced by mutation

• antigenic drift: – small changes in surface antigen

• antigenic shift: – acquire new antigens by

reassortment between avian/swine & human strains

Transmission

Swine influenza virus common throughout pig populations worldwide

Transmission from pigs to humans is not

common and does not always lead to human influenza

• People with regular exposure to pigs are at increased risk of swine flu infection– Meat of an infected animal poses no risk of infection

when properly cooked

• Transmission from one person to another is by droplet or fomite

Mild symptoms : • Fever• sore throat & cough• headache, muscle or joint pains• nausea vomiting, or diarrhea

Those at risk of a more severe infection:• asthmatics • diabetics • obesity • heart disease • immunocompromised• pregnant women

Symptoms in severe cases : Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Low temperature

Complications

Abigail & Brittany Hensel March 7, 1990

Some patients deteriorates around 3 to 5 days after onset

• Respiratory failure requiring immediate admission to an intensive

care unit & mechanical ventilation• myocarditis & collapse - some times

Diagnosis Should not wait for laboratory confirmation

• Diagnosis based on clinical & epidemiological background & start treatment early

For Confirmation a nasopharyngeal or oropharyngeal tissue swab tested with • Real-time or RT-PCR

not required in most people with flu symptoms. test results do not affect recommended course of treatment

For diagnosis of influenza and not H1N1/09 flu more widely available tests:

Rapid influenza diagnostic tests (RIDT): results 30 minutes • high rate of false negative

patients should be treated empirically based on the level of clinical suspicion

Direct & indirect immunofluorescence assays (DFA & IFA): take 2–4 hours

The flu virus is constantly mutating

Humans will probably never be immune from the flu

Natural immunity is not very strong

Role of immunization

Influenza immunization

Not 100% effective

Scientists choose the predominant strains

Chosen the year before

Swine flu vaccines

1. Nasal spray vaccine released in early October 2009 • live attenuated H1N1 virus

approved for use in healthy individuals age 2 - 49

not be used in pregnancy or immunocompromised

2. Injectable vaccine • Made from killed H1N1

used from 6 months to the elderly including pregnant females

Antiviral agents Oseltamivir (Tamiflu) and zanamivir

• used to prevent or reduce influenza A and B symptoms

• Efficacy reduces if the flu symptoms already have been present for 48 hours or more

Supportive measures in severe infection • ventilation support • treatment of other infections like pneumonia

Prophylaxis Avoid crowded places Well ventilated houses Covering mouth & nose while coughing /

sneezing Avoid touching nose & eyes

Frequent hand washing

That’s all in this session !