Transcript Viral Pneumonia - University of Utah

Viral Pneumonia
Fellows conference
Cheryl Pirozzi, MD
September 7, 2011
oregonaidshotline.wordpress.com
Viral Pneumonia
• Epidemiology
• General clinical features
• Specific pathogens
http://www.armageddononline.org/viruses.html
Viral pneumonia: Not just for kids!
Viral Pneumonia
• Viruses recently recognized as important pathogens
in CAP due to improved diagnostic tests (PCR)
• Cause of 2 - 35% of CAP in adults (more in kids)
• Recent emergence of new viral respiratory pathogens
Marcos MA, Esperatti M, and Torres A. Viral pneumonia. Curr Opin Infect Dis 22:143–147
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Risk factors for viral PNA in adults
• Elderly: Higher rates of hospitalization and death
from viral PNA in persons >60 yo
• COPD and asthma: frequently complicated by
respiratory viral infections
• Immunocompromised pts at increased risk
Marcos MA, Esperatti M, and Torres A. Viral pneumonia. Curr Opin Infect Dis 22:143–147
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Risk factors for viral PNA in adults
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Who gets viral pneumonia?
• Johnstone et al. Chest 2008;134;1141-1148
• 193 adults hospitalized with CAP, 47% with severe
CAP, 15% viral and 4% mixed viral/bacterial
• Patients with viral PNA were
– older (76 vs 64),
– more likely to have cardiac disease (66% vs 32%),
– more frail (48% vs 21% limited ambulation)
• Most common viruses: influenza, hMPV, and RSV
• Similar presentations, no difference in outcome
compared with bacterial PNA
– Viral PNA less likely to have lobar infiltrate (62% vs 84%)
and abnl WBC, almost all Oct – May
• Recommended routine isolation for all PNA pts.
Clinical syndromes
• Upper respiratory tract (cold, pharyngitis, bronchitis)
• Bronchiolitis: acute inflammatory disorder of small
airways
– obstruction with air trapping, hyperinflation, wheezing.
– Most common < 2 yo
– RSV most common, also human metapneumovirus,
parainfluenza viruses, influenza A and B viruses,
adenoviruses, measles virus, and rhinovirus
• Pneumonia
– Similar presentation to bacterial PNA
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Diagnosis
• Nasal swab specimens, nasal aspirates, or combined
nose and throat swab specimens.
• Sputum, endotracheal aspirate samples, or BAL
• Rapid antigen detection, viral culture and PCR
methods
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Specific viral pathogens
Ruuskanen et al. Viral pneumonia. Lancet. 2011 Apr 9;377(9773):1264-75
Case 1
• 75 yo woman (previously healthy) presents in December with
2 days progressive f/c, dry cough, SOB, myalgias, and this CXR:
• What is this most likely to be?
Case 1
• 75 yo woman (previously healthy) presents in December with
2 days progressive f/c, dry cough, SOB, myalgias, and this CXR:
• What is this most likely to be?
A) CMV PNA
B) Influenza
C) adenovirus
D) RSV
E) CHF
Case 1
• 75 yo woman (previously healthy) presents in December with
2 days progressive f/c, dry cough, SOB, myalgias, and this CXR:
• What is this most likely to be?
A) CMV PNA
B) Influenza
C) adenovirus
D) RSV
E) CHF
Influenza
• Most common cause of viral PNA in adults
• family Orthomyxoviridae, Type A,B,C
• 2 envelope glycoproteins, Antigenic variation in H
and N leads to epidemic nature
– Hemagglutinin (H) initiates infectivity- binds to cell
– Neuraminidase (N) protein cleaves new virus allowing
spread
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Influenza
• Annual winter epidemics x 6-8 wks
(year round in tropics)
• Transmitted by small particle
aerosols
• 2-3 day incubation period
• Max virus shedding is at onset of
illness, continues for 5 to 7 days
Ruuskanen et al. Viral pneumonia.
Lancet. 2011 Apr 9;377(9773):126475
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Influenza
• Influenza pandemics occur when new viruses are introduced
into the population
• Historic pandemics of 1918 (H1N1- 50 million deaths
worldwide), 1957 (H1N1 and H2N2), 1968 (H3N2)
• Avian influenza H5N1 – 1997 outbreak, 58% with PNA
• Novel H1N1 influenza A virus emerged in Mexico and USA in
Spring 2009
– High risk populations: infants, young kids, healthy adults
20-40s, pregnant/postpartum women,
immunocompromised, obesity, DM, COPD, asthma
– Elderly less susceptible to H1N1 due to prior exposure
– Mortality in hospitalized pts 7% -17%
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Influenza
• Each year, 300,000 hospitalizations (63% in >65 yo),
and 36,000 deaths (85% in >65 yo) due to influenza
• 30% of pts hospitalized for influenza have CXR
infiltrates
• secondary bacterial PNA in ? ~10%
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Influenza
Clinical manifestations
• Acute onset fever, chills, dry cough, dyspnea,
• Pharyngeal pain, nasal congestion
• HA, myalgias, malaise, anorexia, GI sxs
• Altered mental status (more in older persons)
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Influenza
Imaging
• CXR may have bilateral reticulonodular infiltrates, sometimes
lower zone predominant
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Influenza
• Secondary bacterial PNA
– Mst common in elderly, or underlying pulm or cardiac dz
– Period of improvement followed by increased cough,
sputum production, and consolidation
– Mst common Strep pneumo, then S. aureus and Grp A
Strep
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Treatment of Influenza
Vaccines:
• Inactivated virus vaccines: inactivated purified virions
or partially purified HA and NA preparations
– Efficacy 70% to 90% in healthy adults/children if good
antigenic match
• Live, attenuated vaccine
– More effective in children
– In adults equal or less effective than inactivated vaccine
– Contraindicated in pregnant or immunosuppressed
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Treatment of Influenza
Antivirals
• reduce severity and duration of illness
• M2 inhibitors (M2Is) amantadine and rimantadine
– Only influenza A
• Neuraminidase inhibitors (NIs) oseltamivir and
zanamivir
– both influenza A and B
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Available treatment for influenza
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Case 2
• Previously healthy 27 yo man with mild asthma p/w dry
cough, SOB, and wheezing, with O2 sats 80%/RA. The ER did
this chest CT:
• Nasal swab had + RSV PCR
• How should he be treated?
– A) high dose steroids
– B) supportive care
– C) inhaled ribavirin
– D) IVIG
Case 2
• Previously healthy 27 yo man with mild asthma p/w dry
cough, SOB, and wheezing, with O2 sats 80%/RA. The ER did
this chest CT:
• Nasal swab had + RSV PCR
• How should he be treated?
– A) high dose steroids
– B) supportive care
– C) inhaled ribavirin
– D) IVIG
Respiratory syncytial virus (RSV)
• 2nd most common cause of viral PNA in older adults
• Common in winter (November – April, peak Jan-Feb)
• Major cause of serious lower respiratory tract
infections in young children
– Primary RSV infection is nearly universal by age 2 and
repeat infections are common due to incomplete
immunity.
• Also important pathogen in adults, esp elderly,
chronic lung disease, or immunocompromised
• Approx 10,000 deaths in persons > age 65 in the
United States each year from RSV (2nd to influenza)
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
RSV- Pathogenesis
• RSV is a single-stranded, enveloped RNA virus
• Paramyxovirus family, A and B subtypes
• Begins as upper respiratory tract infection, then can
spread to lower respiratory tract and cause
bronchiolitis, bronchospasm, pneumonia, and acute
respiratory failure
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
RSV in adults
Risk factors in adults
• Immunocompromised patients (eg, severe combined
immunodeficiency, leukemia, BMT or lung
transplant)
• Asthma
• Other cardiopulmonary disease
• Elderly, esp institutionalized or with chronic
pulmonary disease or functional disability
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
Influenza vs RSV
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
RSV: Imaging
• CXR: diffuse bilat interstitial
• CT: Bronchitis-bronchiolitis pattern: bronchial wall
thickening and tree-in-bud opacities
• Multifocal ground glass opacities or consolidation
Miller W T , Shah R M AJR 2005;184:613-622
RSV Testing
•
•
•
Culture: Not sensitive or specific in adults
Serologically: RSV-specific IgM or rise in IgG
Antigen detection by DFA or EIA
•
•
Sensitivity depends on specimen: nasal wash (15%),
endotracheal secretions (71%), BAL (89%)
Reverse transcription-PCR (RT-PCR)
•
•
In adult nasal swabs: 73% sensitive and 99% specific
Recommendation:
–
–
Send nasopharyngeal swab for culture, + PCR if pt is
severely ill / immunocompromised
Consider DFA if BAL or endotracheal specimen
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
Falsey, Walsh. Clin Microbiol Rev. 2000 July; 13(3): 371–384.
Treatment of RSV
•
•
•
•
•
Generally supportive: fluids, oxygen, and antipyretics
No data to support steroids or bronchodilators
Ribavirin (aerosolized, IV, PO)
IVIG or RSV-IVIG
Immunomodulators: Palivizumab (PVZ)
– RSV-specific monoclonal Ab
• Treatment with ribavirin ± IVIG and/or palivizumab
is indicated in BMT or transplant pts, but there is
insufficient data to support treating healthy adults
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
Shah et al. Blood. 2011;117(10):2755-2763
Treatment of RSV
• Prevention
– Droplet precautions
– No licensed RSV vaccination at this time; however, in
progress
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med. 2007;28(2):171-181
Human metapneumovirus (hMPV)
• Paramyxovirus, closely related to RSV
• Common in children, but also common cause of PNA
in immunocompromised and elderly adults
• Often coinfection with RSV and other resp viruses
• Droplet transmission
• Winter outbreaks
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Human metapneumovirus (hMPV)
• Clinical: ranges from mild URI to severe bronchiolitis
and pneumonia
• In general similar presentation to RSV, though less
severe
• Diagnosis: PCR most sensitive, also serology and
culture
• Treatment:
– Supportive
– No effective antivirals or vaccines, though ribavirin has in
vitro activity and has been used
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Parainfluenza
• Paramyxovirus RNA virus
• Outbreaks fall-spring, every 2-3 yrs
• Direct contact by respiratory secretions or large
aerosols
• Incubation 3-6 days
• Common cause of croup, bronchiolitis, or PNA in
kids, but can also cause PNA in adults, elderly, and
immunosuppressed, esp BMT pts
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Parainfluenza
• Diagnosis
– Ag or PCR in respiratory secretions or BAL
• Treatment and prevention
– aerosolized ribavirin has been used in children and BMT
pts, but no trials showing efficacy
– No vaccine
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Coronaviruses
•
•
•
•
•
Enveloped RNA viruses
Frequent cause of common cold
4-15% of acute respiratory disease in adults, but rarely PNA
Most common winter and early spring, outbreaks q. 2-3 yrs
Incubation period 3 to 4 days
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Severe Acute Respiratory Syndrome (SARS)
• HuCoV-SARS: group II coronovirus
• emerged in southern China in spring
2003 and rapidly spread worldwide.
• incubation period 2 to 10 days
• Clinical presentation:
–
–
–
–
Cough and dyspnea, fever, chills /rigors, myalgias, diarrhea
20% of patients required respiratory support.
Mortality 11% for all ages but much higher in older adults
Some developed pulmonary fibrosis after acute illness
bryanking.net
• Pathology: diffuse alveolar damage
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
SARS Imaging
• Chest CT:
unilateral or
bilateral GGO,
interstitial
thickening, Mst
common
peripheral lower
lung zones
Top: 37-yo man
with bilateral
patchy GGO
without evidence
of fibrosis, with
random
distribution in
the transverse
plane.
Bottom: 22-yearold female SARS
patient with
random
distribution of
fibrosis, traction
bronchiectasis
(arrowheads), and
lung distortion,
with concomitant
GGO
Hsu H et al. Chest 2004;126:149-158
Severe Acute Respiratory Syndrome (SARS)
• Diagnosis
– (PCR) detection in sputum, also blood and stool
– Serum Abs (rise at 2-3 weeks)
• Treatment – during the outbreak, treatment with:
– ribavirin, protease inhibitors (lopinavir/ritonavir)
– High dose steroids
– type I interferons, chloroquine (unclear mechanism)
• In retrospect unclear that any were effective, recommended
treatment is supportive
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Cytomegalovirus (CMV)
• gammaherpesvirus subfamily of the herpesviruses
• Transmitted through direct contact
– Virus excreted in urine, saliva, stool, tears, breast milk,
vaginal secretions, and semen
• No seasonal patterns
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Cytomegalovirus (CMV)
• In immunocompetent persons, most infections are
subclinical: can cause pharyngitis, rarely PNA
• In immunocompromised, important cause of PNA
• In BMT pts, mst common infectious cause of
interstitial PNA, with high mortality
– Greatest risk of CMV PNA 30-90 days after BMT
• Lung transplant recipients: can cause PNA,
pneumonitis, and lead to bronchiolitis obliterans
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Cytomegalovirus (CMV)
• Clinical: fever, nonproductive cough, dyspnea,
Crackles, tachypnea, hypoxemia
• May have mild neutropenia, thrombocytopenia, and
elevated liver enzymes
• Imaging: bilat diffuse miliary or interstitial infiltrates,
middle and lower lung fields
– On CT small nodules,
consolidation, and GGOs
• Path: eosinophilic intranuclear
viral inclusions
bjr.birjournals.org
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Cytomegalovirus (CMV)
• Treatment: PNA is difficult to treat
– Ganciclovir and IV CMV immune globulin reduces mortality
from approx 90% to 50%
– Cidofovir and foscarnet unclear efficacy
• Prevention in high risk pts
– No vaccines
– CMV-Seronegative BMT pts should only get leukocyte
reduced/CMV-seroneg blood products
– In CMV mismatched solid organ transplant recipients,
posttransplant prophylaxis with ganciclovir
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Case 3
• 18 yo man p/w acute respiratory failure 10 days after
cleaning out a very dirty dusty cellar (including a nice
family of deer mice)
• What might you be worried about?
Hantavirus
• Bunyavirus family, single strand RNA virus
– Many different viruses associated with different rodent
hosts
– Sin Nombre Virus (SNV) associated with deer mouse
• Transmission by contact with infected rodent poop
(infectious for 150 days post-rodent infection!)
– No person-person, except possibly in one outbreak in
South America
• Incubation 8-20 days
• SW outbreak in 1993
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
forces.si.edu
Hantavirus
• Severe, often fatal PNA
• Clinical: f/c, myalgias, GI sxs, then after a few days progressive
nonproductive cough, dyspnea
• Pathogenesis: capillary leak and noncardiogenic pulmonary
edema
• Labs: thrombocytopenia, left shift with circulating
myeloblasts, mildly elevated LFTs
• CXR: bilateral infiltrates c/w ARDS
• Mortality 30-40%
• Also causes cardiopulmonary and
hemorrhagic fever with renal disease
syndrome
cdc.gov
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Hantavirus
• Diagnosis
–  Hantavirus IgM and IgG at time of presentation
– Serum PCR
• Treatment:
– Supportive
– High dose steroids, ECMO possibly effective
– Ribavirin effective in vitro, no good trials showing efficacy
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Herpes Simplex Viruses (HSV)
• HSV-1 most associated with respiratory disease
• Transmitted by respiratory secretions, vesicle fluid on
close contact
• 30-100% of adults are seropositive, asymptomatic
respiratory shedding in 1-2% of seropositive adults
• Cause of PNA in neonates, and in severely
immunocompromised adults esp on mechanical
ventilation, eg malignancy, burns, transplant pts
• Extension of infection from tracheobronchial tree to
the lung or hematogenous dissemination
• Associated with ARDSMurray and Nadel’s Textbook of Respiratory Medicine 5 Edition
th
Herpes Simplex Viruses (HSV)
• Can cause focal PNA or diffuse interstitial PNA
• CT: multifocal GGOs, nonspecific
• Diagnosis
– Frequently found in BAL (by PCR or culture) of critically ill
pts due to spread/aspiration from oropharynx, but unclear
if true pathogen
• Treatment
– IV acyclovir, alternative foscarnet
– Inconsistent data to support effectiveness of antiviral
treatment on the outcome of critically-ill patients
Simoons-Smit et al.Herpes simplex virus type 1 and respiratory disease in critically-ill patients: Real pathogen
or innocent bystander? Clin Microbiol Infect. 2006 Nov;12(11):1050-9.
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Measles
• Uncommon here due to vaccination, but in resourcepoor countries (and damn hippies) can cause fatal
PNA
• Morbillivirus genus of the Paramyxoviridae family
• Epidemics q. 2-5 yrs
• Airborne transmission, highly contagious
• Incubation 9-14 days
• Mortality 0.1% in developed coutries, 2-25% in
developing countries, due to respiratory or
neurologic dz
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Measles- clinical
• Prodrome 2-8 days: fever, cough, anorexia,
conjunctivitis, coryza, Koplik’s spots
• Then maculopapular erythematous rash
from face/neck  trunk  extremities
• Few days after rash appears,
defervescence and sx improvement
• Lower respiratory tract involvement in 450% with bronchitis, PNA, or bronchiolitis
• In immunocompromised, can cause lethal
giant-cell PNA, incl pregnant, HIV pts (40%
mortality) and oncology pts (70%
mortality)
www.nlm.nih.gov/
http://missinglink.ucsf.edu
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Measles- clinical
• CXR: multilobar reticulonodular infiltrate
• Secondary bacterial infection in 30% to 50%
– Haemophilus influenzae, Neisseria meningitidis, and S.
pneumoniae
• Other complications: hepatitis, encephalitis, keratitis,
mesenteric adenitis, severe diarrhea
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Measles
• Diagnosis:
– respiratory secretions or urine show multinucleated giant
cells, + immunoflourescent staining
• Prevention:
– live attenuated virus = >90% durable immunity
• Treatment:
– Supportive care
– Vitamin A improves mortality and recovery time
– Ribavirin in vitro activity, but no proven clinical efficacy
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Adenovirus
• Nonenveloped DNA viruses
• Common cause of pharyngitis, tracheitis, and bronchitis
• Rare cause of pneumonia in adults and children
– Clinical characteristics similar to those of other pneumonias
• In transplant patients and other immunosuppressed pts can
cause fatal pneumonia and disseminated infection, with
hepatitis, hemorrhagic cystitis, and renal failure
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Adenovirus
Treatment and prevention
• No proven antiviral treatment
• Cidofovir has the most in vitro activity and has been used with
some success in seriously ill and/or immunocompromised
patients (case reports, no RCTs)
• Effective live oral vaccines were developed for military, but
are no longer produced
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Rhinovirus
• The most common cause of URIs, sinusitis, OM, and
bronchitis
• Causes PNA and bronchiolitis in infants and severe
PNA in adult transplant and oncology pts
• Diagnosis: culture, rapid Ag or PCR tests
• Treatment: symptomatic
– Pleconaril? – not currently available.
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Case 4
• 30 yo woman 30 wks pregnant p/w SOB, dry cough,
hemoptysis, hypoxia, and this funny rash:
Case 4
• 30 yo woman 30 wks pregnant p/w SOB, dry cough,
hemoptysis, hypoxia, and this funny rash:
• And this CXR:
Case 4
• 30 yo woman 30 wks pregnant p/w SOB, dry cough,
hemoptysis, hypoxia, and this funny rash:
• How should she be treated?
–
–
–
–
–
A) supportive
B) high dose steroids
C) ribavirin
D) acyclovir
E) oseltamivir
Case 4
• 30 yo woman 30 wks pregnant p/w SOB, dry cough,
hemoptysis, hypoxia, and this funny rash:
• How should she be treated?
–
–
–
–
–
A) supportive
B) high dose steroids
C) ribavirin
D) acyclovir
E) oseltamivir
Varicella-Zoster Virus (VZV)
• Highly contagious herpesvirus
• Incubation period 2 weeks
• Varicella (chickenpox) outbreaks usually winterspring
• Respiratory tract infection leads to viremic
dissemination
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Varicella-Zoster Virus (VZV)
Clinical
• Usually fever, malaise, or pharyngitis, then rash from head to
trunk/extremities (lesions in various stages)
• VZV PNA in 1/400 cases, with 10-30% mortality
• In immunocompromised children and adults, more severe
course with high fevers, PNA , meningoencephalitis, hepatitis
• Severe PNA in 10% of varicella infections during pregnancy
• PNA can occur in healthy adults (25x more frequently than
kids)
– Smoking is RF
• Sxs usually 1-6 d after rash onset
• Cough, dyspnea, pleuritic CP, hemoptysis
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Varicella-Zoster Virus (VZV)
• CXR: diffuse nodular infiltrates, which can resolve with miliary
calcific densities, also hilar adenopathy, pleural effusions,
peribronchial infiltrates
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Varicella-Zoster Virus (VZV)
• Diagnosis
– Clinical (rash + PNA)
– Lesion scrapings (Tzank smear) sensitivity 70% to 85%
– Direct immunofluorescence for VZV antigen in lesions
– BAL PCR
• Treatment
– IV acyclovir x 5-7 days is effective
– Steroids controversial; no good data
• Prevention
– Live, attenuated varicella vaccine 50-90% effective
Murray and Nadel’s Textbook of Respiratory Medicine 5th Edition
Characteristics of specific viral pathogens
• Table
• CID 2006:42
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24
Summary of antiviral treatment
•
•
•
•
•
•
•
•
•
•
•
•
Influenza – amantadine, oseltamivir
RSV – ribavirin
Human metapneumovirus – supportive
Parainfluenza – supportive
SARS – supportive (ribavirin and lopinavir unclear)
CMV – ganciclovir
Hantavirus – maybe ribavirin
HSV – acyclovir
Measles – vitamin A, maybe ribavirin
Adenovirus – Cidofovir
Rhinovirus – supportive
Varicella-Zoster Virus – acyclovir
Conclusions
• Viral PNA is a big deal for adults too, especially
elderly and immunocompromised
• Clinical presentation of viral PNAs are similar
to each other and to bacterial PNA – think
about viral testing and isolation
• Only some have effective antivirals
References
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•
•
•
•
•
•
•
•
•
Johnstone J, Majumdar SR, Fox JD, Marrie TJ. Viral infection in adults hospitalized with
community-acquired pneumonia: prevalence, pathogens, and presentation. Chest. 2008
Dec;134(6):1141-8. Epub 2008 Aug 8
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb
15;42(4):518-24. Epub 2006 Jan 6.
Jordi Rello and Aurora Pop-Vicas. Clinical review: Primary influenza viral pneumonia. Crit
Care. 2009; 13(6): 235.
Rothberg MB, Haessler SD. Complications of seasonal and pandemic influenza. Crit Care Med.
2010 Apr;38(4 Suppl):e91-7.
Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. Viral pneumonia. Lancet. 2011 Apr
9;377(9773):1264-75. Epub 2011 Mar 22.
Marcos MA, Esperatti M, and Torres A. Viral pneumonia. Curr Opin Infect Dis 22:143–147
Falsey A. Respiratory Syncytial Virus Infection in Adults. Semin Respir Crit Care Med.
2007;28(2):171-181
Shah J, Chemaly R. Management of RSV infections in adult recipients of hematopoietic stem
cell transplantation. Blood. 2011;117(10):2755-2763
Hsu et al. Correlation of HRCT, symptoms, and pulmonary function in patients during
recovery from Severe Acute Respiratory Syndrome. Chest 2004; 126:149-158
Simoons-Smit AM, Kraan EM, Beishuizen A, Strack van Schijndel RJ, Vandenbroucke-Grauls
CM.Herpes simplex virus type 1 and respiratory disease in critically-ill patients: Real pathogen
or innocent bystander? Clin Microbiol Infect. 2006 Nov;12(11):1050-9.
Available treatment for viral PNAs
Ruuskanen et al. Viral pneumonia. Lancet. 2011 Apr 9;377(9773):1264-75
Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. 2006 Feb 15;42(4):518-24