VIRAL CONDITIONS THAT PRESENT AS FEVER, COUGH, AND MALAISE
VIRAL
Rhinovirus Infection
CONDITIONS
Etiology Rhinovirus
 Family Picornaviridae
 Small (15 to 30 nm)
 Nonenveloped, single-
stranded RNA virus
 3 genetic species:
a. HRV-A
b. HRV-B
c. HRV-C
 Acid-labile; almost completely
inactivated at pH ≤ 3
 Grow preferentially at 33°-
34°C (temp of human nasal
passages) rather than at 37°C
(temp of the lower respiratory
tract)
 Of the 102 recognized
serotypes of rhinovirus
a. 91 use intercellular
adhesion molecule 1
(ICAM-1) as a cellular
receptor; “major” receptor
group
b. 10 use the LDL receptor;
“minor” receptor group
c. 1 uses decay-
accelerating factor
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
Coronavirus Infection
Coronavirus
 Family Coronaviridae
 100-160 nm in diameter
 Pleomorphic, single-stranded
RNA virus
 Crownlike appearance
produced by the club-shaped
projections that stud the viral
envelope
 Three antigenic and genetic
groups
a. HCoV-229E (group 1)
b. HCoV-OC43 (group 2)
c. SARS-CoV (distantly
related member of group
2)
 Human coronaviruses
- Difficult to cultivate in vitro
- Some strains grow only in
human tracheal organ
cultures rather than in
tissue culture
 SARS-CoV
- an exception; ready
growth in African green
monkey kidney (Vero E6)
cells
Human Respiratory Syncytial
Virus (HRSV) Infection
Human Respiratory Syncytial Virus
(HRSV)
 Family Paramyxoviridae
 Genus Pneumovirus
 ~ 150 to 350 nm
 Enveloped, single-stranded RNA
virus
 So named due to its replication in
vitro that leads to the fusion of
neighboring cells into large
multinucleated syncytia
 Codes 11 virus-specific proteins
 Viral RNA is contained in a helical
nucleocapsid surrounded by a
lipid envelope bearing 2
glycoproteins
 2 glycoproteins:
a. G protein
 by which the virus
attaches to cells
b. F (fusion) protein
 facilitates entry of the
virus into the cell by
fusing host and viral
membranes
 Single antigenic type with 2
distinct subgroups (A and B) and
multiple subtypes within each
subgroup
 Antigenic diversity is reflected by
differences in the G protein
 F protein highly conserved
 Both antigenic groups can
circulate simultaneously in
outbreaks; there are typically
alternating patterns in which 1
subgroup predominates over 1- to
2-yr periods
Parainfluenza Virus Infection
Parainfluenza Virus
 Family Paramyxoviridae
 Genera:
a. Respirovirus
b. Rubulavirus
 150-200 nm in diameter
 Enveloped, single-stranded RNA
virus
 Codes 6 structural and several
accessory proteins
 Viral RNA is enclosed in a helical
nucleocapsid
 Envelope is studded with 2
glycoproteins:
a. Glycoprotein with both
hemagglutinin and
neuraminidase activity
b. Glycoprotein with fusion
activity
 5 serotypes (1,2, 3, 4A and 4B)
- Share certain antigens with
other members of
Paramyxoviridae family,
including mumps and
Newcastle disease viruses
Adenovirus Infection Influenza Virus Infection
Adenovirus Influenza virus
 Family Adenoviridae  Family Orthomyxoviridae
 Genus Mastadenovirus (51  Influenza A, B, C viruses
serotypes) constitute 3 separate genera
 70-80 nm in diameter  Designation of influenza viruses
is based on the anntigenic
 Linear double-stranded DNA characteristics of the:
 Codes for structural and non- a. Nucleoprotein (NP)
structural polypeptides b. Matrix (M) protein antigens
 Influenza A
 Characteristic morpholology: - Subtyped on the basis of
a. Icosahedral shell with 20 the surface hemagglutinin
equilateral triangular (H) and neuraminidase (N)
faces and 12 vertices antigens
- Individual strains are
b. Protein coat (capsid) designated accdg to the
 hexon subunits – site of origin, isolate
with group-specific number, yr of isolation,
and type-specific and subtype
antigenic - Has 16 distinct H subtypes
determinants and 9 distinct N subtypes
- H1-3 and N1-2 –
 penton subunits at associated with epidemics
each vertex – contain in humans
group-specific
antigens  Influenza B and C
- Similarly designated, but H
 a fiber with a knob at and N do not receive
the end projects from subtype designations due
each penton – to less intratypic variations
contains type-specific in their antigens
and some group-
specific antigens  Influenza A and B
- Major human pathogens
 Six subgroups (A-F) on the - Morphologically similar
basis of the homology of DNA - Virions irregularly shaped
genomes and other properties spherical particles
- 80-120 nm in diameter
 The replicative cycle of - Lipid envelop with H and N
adenovirus may result in: glycoproteins
a. Lytic infection of cells
b. Establishment of a latent - Genomes consists of 8
infection (primarily single-stranded RNA
lymphoid cell segments, which code for
involvement) structural and non-
structural proteins
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 VIRAL
Rhinovirus Infection
CONDITIONS
Epidemiology  Prominent cause of common
cold
 Detected in up to 50% of
common cold-like illnesses by
tissue culture and PCR
techniques
 Rates of infection:
- Higher among infants
and young children
- Decrease with increasing
age
 Occur throughout the year
- Seasonal peaks in early
fall and spring in
temperate climates
 Most often introduced into
families by preschool or
grade-school children <6 yrs
old
 Worldwide in distribution
 By adulthood, nearly all
individuals have neutralizing
antibodies to multiple
serotypes, although the
prevalence of antibody to any
one serotype varies widely
 Multiple serotypes circulate
simultaneously
 no single serotype or group
of serotypes has been more
prevalent than the others
Mode of  direct contact with infected
Transmission secretions (respiratory
droplets)
 self-inoculation of the
conjunctival or nasal mucosa
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
Coronavirus Infection
 Present throughout the world
 Serum antibodies are acquired
early in life and increase in
prevalence with advancing age
- >80% of adult populations
have antibodies as
measured by ELISA
 Account for 10-35% of
common colds, depending on
the season
 Prevalent in late fall, winter,
and early spring
- times when rhinovirus
infections less common
 SARS
- Occurred in 2002-2003
- Outbreak apparently
began in Southern China
- 90% of cases occurred in
China and HK
- Horseshoe bat  natural
reservoir of SARS-CoV
 both large and small aerosols
 fecal-oral route
Human Respiratory Syncytial
Virus (HRSV) Infection
 Major respiratory pathogen of
young children
 Foremost cause of lower
respiratory disease in infants
 Infection seen throughout the
world
 Annual epidemics occur in late
fall, winter, or spring; last up to 5
months
 rarely encountered in the
summer
 Rates of illness
- Highest among infants (1-6
months of age); peak 2-3
months of age
 In older children and adults,
reinfection with HRSV is frequent
but disease is milder than in
infancy
 close contact with contaminated
fingers or fomites
 self-inoculation of the conjunctiva
or anterior nares
 coarse aerosols (coughing and
sneezing)
Parainfluenza Virus Infection
 Distributed throughout the world
 Infection is acquired in early
childhood
- By age 5, most children have
antibodies to serotypes 1, 2,
3  antigenic drifts (minor
 Types 1 and 2
- Cause epidemics during the
fall
- Often occurring in an
alternate-year pattern
 Type 3
- Detected during all seasons
of the year
- Epidemics occurred annually
in the spring
 Rank second to HRSV as causes
of lower respiratory tract illness in
young children
 Type 1
- Most frequent cause of croup
in children
 Type 2
- Generally less severe
disease
 Type 3
- Important cause of
bronchiolitis and pneumonia
in infants
- Frequently causes illness
during the 1st month of life,
when passively acquired
maternal antibody is still
present (unlike types 1, 2)
 person-to-person contact
 large droplets
Adenovirus Infection
 Most frequently affect infants
and children
 Occur throughout the year but
most common from fall to
spring
 Nearly 100% of adults have
serum antibody to multiple
serotypes  indicating that
infection is common in children
 Most common isolates from
children
- Types 1,2,3,5
 Acute respiratory disease in
military recruits in winter and
spring
- Types 4, 7
- Types 3, 14, 21
 inhalation of aerosolized virus
 inoculation of virus into
conjunctival sacs
 fecal-oral route
Influenza Virus Infection
Influenza A
 Most extensive and severe
outbreaks of influenza are
caused by influenza A viruses
 antigenic shifts (major
antigenic variation)
antigenic variation)
 Pandemic and interpandemic
Influenza B
 Causes outbreaks that are less
extensive
 Associated with less severe
disease than those caused by
influenza A virus
 Its hemagglutinin and
neuraminidase undergo less
frequent and less extensive
variation
 Outbreaks seen most frequently
in schools and military camps;
occasionally in institutions for
the elderly
 Reye’s syndrome – most
serious complication
Influenza C
 Relatively minor cause of
disease in humans
 Associated with common cold-
like symptoms and occasionally
with LRT illness
 The widespread prevalence of
serum antibody to this virus
indicates that asymptomatic
infection may be common
Most prominent high risk
conditions associated with
influenza
a. Chronic cardiac and
pulmonary diseases
b. Old age
 aerosols (cough and sneezes)
 hand-to-hand contact
 fomite transmission
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 VIRAL
Rhinovirus Infection
CONDITIONS
Clinical  Incubation period
Manifestations - 1-2 days
 Usually begins with rhinorrhea
and sneezing + nasal
congestion
 Sore throat
 frequent
 initial complaint (in some
cases)
 Systemic signs and symptoms
are mild or absent
a. Malaise
b. Headache
 Fever – unusual
 Generally lasts for 4-9 days
 Resolves spontaneously,
without sequelae
 complications related to
obstruction of the Eustachian
tube or sinus ostia (otitis
media or acute sinusitis) can
develop
 Immunosuppressed patients
(BM transplant recipients) 
severe and fatal pneumonias
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
Coronavirus Infection
 Incubation period
- 2-7 days
- (range: 1-14 days)
 SARS usually begins as a
systemic illness marked by:
a. Fever
b. Malasise
c. Headache
d. Myalgia
 Followed in 1-2 days by:
a. Non-productive cough
b. Dyspnea
 Approx. 25% of patients have
diarrhea
 CXR: variety of infiltrates:
a. Patchy areas of
consolidation – most
frequently in peripheral
and lower lung fields
b. Interstitial infiltrates – can
progress to diffuse
involvement
 Severe cases:
- Respiratory function may
worsen during the 2nd wk
of illness  progress to
frank adult respiratory
distress syndrome +
multiorgan dysfunction
- Risk factors:
a. Age >50 yrs old
b. Co-morbidities
(CVD, diabetes,
hepatitis)
c. Pregnant women
- SARS-CoV infection
appears to be milder in
children than in adults
Human Respiratory Syncytial
Virus (HRSV) Infection
 Incubation period
- 4-6 days
 HRSV infection leads to a wide
spectrum of respiratory illnesses
 In infants, 25-40% of infections
result in lower respiratory tract
(LRT) involvement:
a. Pneumonia
b. Bronchiolitis
c. Tracheobronchitis
infants
 Usually begins most frequently
with:
a. Rhinorrhea
b. Low grade fever
c. Mild systemic symptoms +
cough + wheezing
 Recover gradually over 1-2 wks
 Severe cases:
a. Tachypnea
b. Dyspnea
c. Frank hypoxia
d. Cyanosis
e. Apnea
f. PE: diffuse wheezing,
rhonchi, rales
g. CXR: hyperexpansion,
peribronchial thickening, and
variable infiltrates (diffuse
interstitial infiltrates 
segmental or lobar
consolidation
 Risk factors: (illness severe in:)
a. Children born prematurely
b. Those with congenital
cardiac disease
c. Bronchopulmonary dysplasia
d. Nephrotic syndrome
e. Immunosuppression
Parainfluenza Virus Infection
 Incubation period
- 3-6 days (in experimental
infections)
- May be shorter for naturally
occurring disease in children
 occurs most frequently among
children, in whom initial infection
with serotype 1, 2, or 3 is
associated with an acute febrile
illness (in 50-80% of cases)
young children
 children may present with:
a. coryza
b. sore throat
c. hoarseness
d. cough (may or may not be
croupy)
 In severe croup
- Fever persists
- With worsening coryza and
sore throat
- Brassy or barking cough may
progress to frank stridor
 Most children recover over the
next 1 or 2 days (although
progressive airway obstruction
and hypoxia ensue occasionally)
 If bronchiolitis or pneumonia
develops, these may occur:
a. Progressive cough +
wheezing
b. Tachypnea
c. Intercostal retractions
d. Sputum production increases
modestly
e. PE: nasopharyngeal
discharge and oropharyngeal
injection + rhonchi, wheezes,
or coarse breath sounds
f. CXR: air trapping and
occasionally interstitial
infiltrates
Adenovirus Infection
Children
 clinical syndromes:
a. acute URTI + prominent
rhinitis – most common
b. LRT disease
(bronchiolitis, pneumonia)
 Pharyngoconjunctival fever
- types 3 and 7
- A characteristic acute
febrile illness of children
that occurs in outbreaks,
most often in summer
camps
- Lasts for 1-2 weeks
- Resolves spontaneously
a. Bilateral conjunctivitis
(bulbar and palpebral
conjunctivae – granular
appearance)
b. Low-grade fever
(frequently present for the
1st 3-5 days)
c. Rhinitis
d. Sore throat
e. Cervical adenopathy
 Febrile pharyngitis with or
without conjunctivitis
 Whooping cough with or
without Bordetella pertussis
adults
 Acute respiratory disease
- Types 4 and 7
- Most frequently reported
in military recruits
a. Prominent sore throat
b. Gradual onset of fever
(39°C) on the 2nd or 3rd
day of illness
c. Cough
d. Coryza
e. Regional LAD
f. PE: pharyngeal edema,
injection, tonsillar
enlargement with or
without exudate
Influenza Virus Infection
 Incubation period
- 18-72 hours; depending on
the size of the viral
inoculums
 Illness characterized by:
a. Abrupt onset of systemic
symptoms
 headache (generalized
or frontal)
 feverishness (38°-41°C)
 chills
 myalgia (most common
in legs and lumbosacral
area)
 malaise
b. Respiratory tract signs
(cough and sore throat)
cough may last for ≥
1wk
+ substernal discomfort
c. Ocular signs and
symptoms
 pain on motion of the
eyes
 photophobia
 burning of the eyes
d. PE: flushed; skin hot and
dry; diaphoresis; mottled
extremities
e. Pharynx – unremarkable;
injection of mucous
membranes and postnasal
discharge apparent in
some cases
f. Mild cervical LAD
 Indicative of pulmonary
complications
a. Frank dyspnea
b. Hyperpnea
c. Cyanosis
d. Diffuse rales
e. Signs of consolidation
3 of 8
  Clinical features of common
colds: coronavirus vs.
rhinovirus
 mean incubation period of
colds induced by coronavirus
(3 days) – longer than that of
rhinovirus infection
Duration of illness (mean, 6-
7 days) – shorter than that of
rhinovirus infection
 amount of nasal discharges
greater in coronavirus
 Coronavirus other than SARS-
CoV recovered occasionally
from:
a. Infants with pneumonia
b. Military recruits with LRT
disease
 Have been associated
with worsening of chronic
bronchitis
 2 novel coronaviruses isolated
from patients with acute
respiratory illness
a. HCoV-NL63 (group 1)
b. HCoV0HKU1 (group 2)
VIRAL
Rhinovirus Infection Coronavirus Infection
CONDITIONS
Diagnosis  PCR  RT-PCR
- More sensitive than - Rapid diagnosis of SARS-
tissue culture CoV
- Detects rhinovirus RNA - More sensitive than tissue
culture
 Tissue culture - Respiratory tract and
- Rarely undertaken due to plasma (early in illness)
benign, self-limited - Stool and urine (later)
nature of illness
 Tissue culture
 Serum antibody test - Inoculation into vero E6
- Impractical due to many tissue culture cells
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
adults
 Most common symptoms
a. Common cold
b. Rhinorrhea
c. Sore throat
d. Cough
 Occasionally associated with
moderate systemic symptoms:
a. Malaise
b. Headache
c. Fever
 HRSV has been reported to cause
LRT disease with fever, including
severe pneumonia in the elderly
(particularly in nursing-home
residents, among whom its impact
can rival that of influenza
 HRSV pneumonia
- can be a significant cause of
morbidity and death among
patients undergoing stem cell
and solid organ
transplantation
- case fatality rate 20-80%
 sinusitis, otitis media, and
worsening obstructive and
reactive airway disease –
associated with HRSV infection
Human Respiratory Syncytial
Virus (HRSV) Infection
 RT-PCR
- More specific and sensitive
particularly in adults
 Tissue culture
 ELISA or immunofluorescence
- Rapid viral diagnostic
technique
- From nasopharyngeal
washes, aspirates,
nasopharyngeal swabs (less
Older children and adults
 Parainfluenza infections milder
 Present frequently as:
a. Common cold; or
b. Hoarseness (with or without
cough)
 LRT involvement – uncommon
 Severe, prolonged, and even fatal
parainfluenza infection has been
reported in children and adults
with severe immunosuppression,
including hematopoietic stem cell
and solid-organ transplant
recipients
Parainfluenza Virus Infection
 PCR
- Highly specific and sensitive
 Tissue culture
- Viral growth detected by
either hemagglutination or
cytopathic effect
 ELISA or immunofluorescence
- Rapid viral diagnosis
- ID of parainfluenza antigens
in exfoliated cells from
g. CXR: patchy infiltrates (if  Uncomplicated influenza
pneumonia has - Resolves over 2-5 days
developed) - Most patients largely
recovered in 1wk
 Acute diarrheal illness - Cough may persist 1-2
- Types 40 and 41 wks longer
 Hemorrhagic cystitis  COMPLICATIONS:
- Types 11 and 21 - Occur most frequently in:
a. Patients >65 yrs old
 Epidemic keratoconjunctivitis b. Those with certain
- Types 8, 19, 37 chronic disorders
- Associated with c. Pregnancy (2nd or 3rd
contaminated common trimester)
sources (ophthalmic d. Children < 5 yrs old
solutions, roller towels)
- Include:
 Disseminated disease and a. Primary influenza
pneumonia in viral pneumonia
immunosuppressed patients b. Secondary bacterial
(solid-organ or hematopoietic pneumonia
stem cell transplants) c. Mixed viral and
bacterial pneumonia
d. Worsening of chronic
bronchitis
e. Asthma
f. Croup (in children)
g. Sinusitis
h. Otitis media
i. Reye’s syndrome
j. Myositis,
rhabdomyolysis,
myoglobinuria
k. CNS: encephalitis,
transverse myelitis,
Guillain-Barré
syndrome
l. TSS
Adenovirus Infection Influenza Virus Infection
 Rapid viral diagnosis  RT-PCR
a. Immunofluorescence/ - Rapid test detecting viral
ELISA of nasopharyngeal antigens
aspirates, conjunctival or - Most sensitive and specific
respiratory secretions, in vitro test
urine, stool - Detects pandemic A/H1N1
b. PCR virus (2009-2010)
c. Nucleic acid hybridization
 Tissue culture/ chick embryos
 Definitive diagnosis - Isolation of virus within 48-
a. Detection of virus in tissue 72 hours after inoculation
culture (cytopathic
4 of 8
 serotypes of rhinovirus
 WBC count and ESR – not
helpful
 Specific diagnosis
- Isolation of virus from:
a. Nasal washes
b. Nasal secretions
VIRAL
Rhinovirus Infection
CONDITIONS
Treatment  First-line antihistamines
 NSAIDs
 Oral decongestant
 Reduction of activity
 Antibacterial agents – only if
bacterial complications (otitis
media or sinusitis) develop
 Specific antiviral therapy NOT
available
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
- Cytopathic effect seen
within days
 ELISA or immunofluorescence
- Nearly all patients
develop detectable
antibodies in 28 days
after the onset of illness
Coronavirus Infection
 Supportive care to maintain
pulmonary and other organ-
system function
- Mainstay of therapy
 Approach to the treatment of
common colds similar to
rhinovirus-induced illnesses
 NO specific therapy of
established efficacy for SARS
satisfactory)
 Serologic diagnosis may be made
by:
- Comparison of acute and
convalescent-phase
specimen (ELISA,
neutralization, complement-
fixation tests)
- Useful in older children and
adults
- Less sensitive in children (<4
months of age)
 Specific diagnosis:
- Detection of HRSV in:
a. respiratory secretions
b. Sputum
c. Throat swab
d. Nasopharyngeal
washes
Human Respiratory Syncytial
Virus (HRSV) Infection
 Upper Respiratory Tract HRSV
infection
a. Alleviation of symptoms
b. Treatment similar to that for
other viral infections of the
URT
 Lower Respiratory Tract HRSV
infection
a. Hydration
b. Suctioning of secretions
c. Administration of humidified
oxygen and
antibronchospastic agents
(as needed)
d. Severe hypoxia  intubation
and ventilatory assistance
respiratory tract
- Less sensitive than tissue
culture
 Serologic diagnosis of acute and
convalescent-phase specimens
can be established by:
a. Hemagglutinin inhibition
b. Complement fixation
c. neutralization
 Specific diagnosis:
- Detection of parainfluenza
virus in:
a. Respiratory tract
secretions
b. Throat swabs
c. Nasopharyngeal
washings
Parainfluenza Virus Infection
 Mild cases of croup
a. Bed rest
b. Moist air generated by
vaporizers
 Severe cases
a. Hospitalization
b. Close observation for
development of respiratory
distress
c. Humidified oxygen and
intermittent racemic
epinephrine (if acute
respiratory distress
develops)
d. Aerosolized or systemically
administered GC – beneficial
changes)  Acute influenza virus detected
b. Specific ID with in throat swabs,
immunofluorescence or nasopharyngeal swabs/
other immunologic washes, sputum
techniques
 Diagnosis of acute infection
 Epidemiologic setting of: a. Hemagglutinin inhibition
a. Acute respiratory disease b. Complement fixation
in military recruits c. ELISA
b. Certain clinical syndromes
in which outbreaks of
characteristic illness
occurs
(pharyngoconjunctival
fever; epidemic
keratoconjunctivitis)
 Types 40 and 41
- Associated with diarrheal
disease in children
- Require special tissue
culture cells for isolation
- Detected by direct ELISA
of stool
 Serum antibody rise can be
demonstrated by:
a. CF or neutralization test
b. ELISA
c. Radioimmunoassay
d. Hemagglutinin inhibition
test (for adenovirus that
hemagglutinates RBCs)
Adenovirus Infection Influenza Virus Infection
 Only symptom-based treatment  For influenza A and B
and supportive therapy (neuraminidase inhibitors)
a. Zanamivir
 Clinically useful antiviral b. Oseltamivir
therapy has not been c. Peramivir
established
 For Influenza A
(adamantane agents)
 Active in vitro against certain a. Amantadine
adenoviruses b. Rimantadine
a. Ribavirin
b. Cidofovir  Side effects:
a. Zanamivir – exacerbate
bronchospasm in
asthmatic patients
b. Oseltamivir – nausea and
5 of 8

 Aerosolized Ribavirin
- Nucleoside analogue active
in vitro against HRSV
- Modest beneficial effect on
the resolution of LRTI
- “may be considered” for
infants who are severely ill or
who are at high risk for
complications of HRSV
infection
 Not beneficial
a. RSVIg – no longer available
b. Palivizumab – chimeric
mouse-human monoclonal
IgG antibody to HRSV
VIRAL Human Respiratory Syncytial
Rhinovirus Infection Coronavirus Infection
CONDITIONS Virus (HRSV) Infection
Prevention and  Intranasal application of  Strict infection-control  Approved as prophylaxis for
Control interferon spray practices children <2yrs old who have
- Effective prophylaxis bronchopulmonary dysplasia or
- Assoc. with local irritation  No vaccines against known cyanotic heart disease, or who
of the nasal mucosa human coronaviruses were born prematurely
a. RSVIg – no longer
 Help reduce rates of available
transmission b. Palivizumab
a. Thorough hand washing
b. Environmental  Other approaches:
decontamination a. Immunization with purified F
c. Protection against and G surface glycoproteins
autoinoculation of HRSV or generation of
stable, live attenuated virus
vaccines
b. Barrier methods for the
protection of hands and
conjunctivae
 Inactivated whole-virus vaccine –
INEFFECTIVE
String`13 – Level III Block I Module 3 Case 6 (Fever, Cough, Malaise)
 No specific antiviral therapy
 Ribavirin – active against
parainfluenza virus in vitro;
anecdotal reports describe its
clinical use in immunosuppressed
patients
Parainfluenza Virus Infection
 Vaccines under development
vomiting; neuropsychiatric
side effects in children
c. Amantadine – mild CNS
side effects primarily
jitterness, insomnia,
difficulty concentrating
d. Rimantidine – less
frequent CNS side effects
than amantadine
 RIBAVIRIN
- Nucleoside analogue with
activity against influenza A
and B in vitro
- Variably effective against
influenza when
administered as an aerosol
- Ineffective when
administered orally
- Its efficacy as treatment
not established
 Symptom-based treatment for
uncomplicated influenza with
low risk for complications
Adenovirus Infection Influenza Virus Infection
 Live vaccines against types 4  Inactivated (killed) vaccine
and 7 - 50-80% protection
- Use to control illness - LGF and mild systemic
among military recruits symptoms 8-24h after
- Live, unattenuated virus vaccination
administered in enteric- - Mild redness or
coated capsules tenderness at the
vaccination site
- Infection of the GI tract
with types 4 and 7 does  Live attenuated vaccine
not cause disease but - Generated by
stimulates local and reassortment between
systemic antibodies that currently circulating strains
are protective against of influenza A and B virus
subsequent acute and a cold-adapted,
respiratory disease due to attenuated master strain
those serotypes - >90% protective in young
children (>6 months)
- Approved for use in
healthy non-pregnant
persons 2-49 yrs of age
 Chemoprophylaxis: oseltamivir
or zanamivir (84-89%)
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Table 186-1 Illnesses Associated with Respiratory Viruses
Frequency of Respiratory Syndromes
Virus Most Frequent Occasional Infrequent
Rhinoviruses Common cold Exacerbation of chronic bronchitis and Pneumonia in children
asthma
Coronavirusesa Common cold Exacerbation of chronic bronchitis and Pneumonia and bronchiolitis
asthma
Human respiratory Pneumonia and bronchiolitis in young Common cold in adults Pneumonia in elderly and immunosuppressed patients
syncytial virus children
Parainfluenza viruses Croup and lower respiratory tract Pharyngitis and common cold Tracheobronchitis in adults; lower respiratory tract disease in
disease in young children immunosuppressed patients
Adenoviruses Common cold and pharyngitis in Outbreaks of acute respiratory disease in Pneumonia in children; lower respiratory tract and disseminated
children military recruitsb disease in immunosuppressed patients
Influenza A viruses Influenzac Pneumonia and excess mortality in high- Pneumonia in healthy individuals
risk patients
Influenza B viruses Influenzac Rhinitis or pharyngitis alone Pneumonia
d
Enteroviruses Acute undifferentiated febrile illnesses Rhinitis or pharyngitis alone Pneumonia
Herpes simplex viruses Gingivostomatitis in children; Tracheitis and pneumonia in Disseminated infection in immunocompromised patients
pharyngotonsillitis in adults immunocompromised patients
Human Upper and lower respiratory tract Upper respiratory tract illness in adults Pneumonia in elderly and immunosuppressed patients
metapneumoviruses disease in children

a
SARS-associated coronavirus (SARS-CoV) caused epidemics of pneumonia from November 2002 to July 2003 (see text).
b
Serotypes 4 and 7.
c
Fever, cough, myalgia, malaise.
d
May or may not have a respiratory component.

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Table 187-3 Antiviral Medications for Treatment and Prophylaxis of Influenza
Age Group (Years)
Antiviral Drug Children (≤12) 13–64 ≥65
Oseltamivir
Treatment, influenza A and B Age 1–12, dose varies by weighta 75 mg PO bid 75 mg PO bid
Prophylaxis, influenza A and B Age 1–12, dose varies by weightb 75 PO qd 75 mg PO qd

Zanamivir
Treatment, influenza A and B Age 7–12, 10 mg bid by inhalation 10 mg bid by inhalation 10 mg bid by inhalation
Prophylaxis, influenza A and B Age 5–12, 10 mg qd by inhalation 10 mg qd by inhalation 10 mg qd by inhalation

Amantadinec
Treatment, influenza A Age 1–9, 5 mg/kg in 2 divided doses, up to 150 mg/d Age ≥10, 100 mg PO bid ≤100 mg/d
Prophylaxis, influenza A Age 1–9, 5 mg/kg in 2 divided doses, up to 150 mg/d Age≥ 10, 100 mg PO bid ≤100 mg/d

Rimantadinec
Treatment, influenza A Not approved 100 mg PO bid 100–200 mg/d
Prophylaxis, influenza A Age 1–9, 5 mg/kg in 2 divided doses, up to 150 mg/d Age ≥10, 100 mg PO bid 100–200 mg/d

a
<15 kg: 30 mg bid; >15–23 kg: 45 mg bid; >23–40 kg: 60 mg bid; >40 kg: 75 mg bid. For children <1 year of age, see www.cdc.gov/h1n1flu/recommendations.htm.
b
<15 kg: 30 mg qd; >15–23 kg: 45 mg qd; >23–40 kg: 60 mg qd; >40 kg: 75 mg qd. For children <1 year of age, see www.cdc.gov/h1n1flu/recommendations.htm.
c
Amantadine and rimantadine are not currently recommended (2009–2010) because of widespread resistance in influenza A viruses. Their use may be reconsidered if viral susceptibility is reestablished.

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