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Snapshot
  • A 1-year-old toddler is brought to the emergency room for trouble breathing. His parents report that for the past few days, he has had low-grade fevers, nasal congestion, and a cough. Today, he did not appear to want to eat or drink any water. On physical exam, he is saturating 88% on room air. He has a prolonged expiratory phase and diffuse wheezes bilaterally. He has nasal flaring and intercostal retractions. He is given supplemental oxygen and admitted for further management.
Introduction
  • Classification
    • respiratory syncytial virus (RSV)
      • an enveloped, linear, single-stranded, negative-sense RNA virus with a helical capsid
      • a paramyxovirus
      • causes bronchiolitis in infants and atypical pneumonia 
  • Epidemiology
    • incidence
      • more common in the winter
    • demographics
      • children < 2 years of age 
    • risk factors
      • daycare centers
      • exposure to air pollutants such as cigarette smoke
      • cardiopulmonary disease
      • immunodeficiency
      • premature infants
  • Pathogenesis
    • the virus contains surface protein F (fusion), which induces respiratory epithelial cells to form multinucleated giant cells
    • the virus initially infects the upper respiratory tract and travels to the lower respiratory tract within a few days
    • edema of submucosa causes an obstructive pathology in the lungs, causing wheezing and respiratory distress
  • Prevention
    • palivizumab
      • mechanism
        • monoclonal antibody against F protein
      • indication
        • premature infants
        • babies at risk of severe infection (i.e., immunocompromised status)
  • Prognosis
    • typically self-limited
    • more severe in infants < 6 months of age
Presentation
  • Symptoms 
    • low-grade fever
      • a high fever may indicate pneumonia
    • congestion
    • cough
    • poor feeding
    • grunting
  • Physical exam
    • tachypnea
    • bilateral wheezing
    • prolonged expiratory phase
    • increased work of breath
      • nasal flaring
      • intercostal retractions
    • focal crackles
      • in patients with pneumonia
Imaging
  • Chest radiography
    • indication
      • suspected pneumonia
    • findings
      • diffuse patchy infiltrates
Studies
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Asthma
    • distinguishing factors
      • typically recurrent episodes with identifiable triggers
      • history of atopy in the patient or family
  • Foreign body aspiration
    • distinguishing factor
      • unilateral wheezing
Treatment
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • hydration
        • supplemental oxygen
        • superficial nasal suctioning
Complications
  • Hypoxemic respiratory failure
    • treatments
      • oxygen
      • mechanical ventilation

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