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For further information, see CMDT Part 32-06: Common Viral Respiratory Infections

Key Features

  • Bronchiolitis, proliferation and necrosis of bronchiolar epithelium develop, producing obstruction from sloughed epithelium and increased mucus secretion

  • Apnea, low-grade fever, tachypnea, and wheezes

  • Hyperinflated lungs, decreased gas exchange, and increased work of breathing

  • Prematurity and bronchopulmonary dysplasia are major risk factors for severe disease

Clinical Findings

  • Annual epidemics occur in winter and spring

  • Average incubation period is 5 days

  • Inoculation may occur through the nose or the eyes

  • In children

    • Most common cause of acute lower respiratory infection

    • Common cause of acute and recurrent otitis media

  • In adults

    • Causes upper and lower respiratory tract infection with increasingly recognized severity in

      • Persons with comorbid conditions

      • Elderly persons

      • Persons with severe combined immunodeficiency

      • Persons who have undergone lung or bone marrow transplantation

    • Recurrent infections occur throughout life

  • In immunocompromised patients, such as bone marrow transplant recipients, serious pneumonia can occur

Diagnosis

  • Polymerase chain reaction (PCR) is increasingly used

  • Rapid diagnosis possible by viral antigen identification in nasal washings using an ELISA or immunofluorescent assay

  • Multiplex assays in conjunction with influenza A and B tests are available commercially

  • RSV viral load assay values at day 3 of infection correlate with requirement of intensive care and respiratory failure

Treatment

  • Hydration, humidification of inspired air, antibiotic therapy if concomitant bacterial pneumonia is suspected, and ventilatory support as needed

  • Neither bronchodilating agents nor corticosteroids show efficacy in bronchiolitis although individual patients with significant bronchospasm or history of asthma may respond to them

  • Use of aerosolized ribavirin or RSV-enriched IVIG, or both

    • Can be considered in high-risk patients, such as those with a history of bone marrow transplantation

    • Appears to lessen mortality

    • Ribavirin is contraindicated in pregnancy

  • Palivizumab

    • Prophylactic monoclonal antibody

    • Effective in high-risk infants

      • Premature infants < 32 weeks gestational

      • Infants 32- to 35-weeks gestational age with additional risk factors, such as congenital heart and lung diseases, Down syndrome

    • Not proven effective among adults with RSV

  • Nirsevimab

    • Monoclonal antibody

    • Effective in preventing RSV-associated lower respiratory tract infections in premature infants

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