Patient will present as → a 45-year-old male with a one-week history of hacking, non-productive cough, low-grade fever, malaise, and myalgias. The chest x-ray reveals widespread bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.
Adults → The influenza viruses are the most common viral cause of pneumonia
- Primary influenza pneumonia manifests with persistent symptoms of cough, sore throat, headache, myalgia, and malaise for more than three to five days. The symptoms may worsen with time, and new respiratory signs and symptoms, such as dyspnea and cyanosis, appear.
- Bacterial pneumonia complicates approximately 0.5 percent of influenza cases in healthy young individuals and at least 2.5 percent of cases in older individuals and those with predisposing conditions. Bacterial pneumonia typically occurs within a few days of influenza onset
Kids → RSV, 1st episode of wheezing
- Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection in infants and children and the second most common viral cause of pneumonia in adults
- Patients with RSV pneumonia typically present with fever, nonproductive cough, otalgia, anorexia, and dyspnea. Wheezes, rales, and rhonchi are common physical findings.
Parainfluenza virus pneumonia
- Parainfluenza virus (PIV) is second in importance only to RSV as a cause of lower respiratory tract disease in children and pneumonia and bronchiolitis in infants younger than 6 months.
- The signs and symptoms include fever, cough, coryza, dyspnea with rales, and wheezing.
Chest radiography usually demonstrates bilateral lung involvement, but none of the viral etiologies of pneumonia result in pathognomonic findings with CXR
- Rapid antigen testing for influenza
- RSV nasal swab
- Cold agglutinin titer that is negative
Oseltamivir (Tamiflu) is the preferred antiviral agent for the treatment of influenza
- Alternative antiviral agents for the treatment of uncomplicated influenza include baloxavir (oral single dose), zanamivir (inhaled regimen twice daily for five days), or peramivir (parenteral single dose)
- Amantadine and Rimantadine treat only influenza A. Their efficacy in patients with influenza viral pneumonia or severe influenza is unknown.
RSV pneumonia
- Ribavirin is the only effective antiviral agent available for the treatment of RSV pneumonia, but there are conflicting data regarding its efficacy.
PIV pneumonia
- Treatment is mainly supportive, but aerosolized and oral ribavirin have been associated with a reduction in PIV shedding and clinical improvement in immunocompromised patients
Chest radiograph from a patient with viral pneumonia showing widespread bilateral interstitial infiltrates
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Question 1 |
A 15 year-old male presents with a 1 week history of hacking non-productive cough, low grade fever, malaise and myalgias. Examination is unremarkable except for a few scattered rhonchi and rales upon auscultation of the chest. The chest x-ray reveals interstitial infiltrates and a cold agglutinin titer was negative. Which of the following is the most likely diagnosis?
acute bronchitis Hint: While the patient's clinical symptoms of dry cough and rhonchi support this diagnosis, the chest x-ray would be normal or only show a mild increase in bronchovascular markings, not infiltrates. | |
viral pneumonia | |
mycoplasma pneumonia Hint: While the gradual onset of symptoms suggest mycoplasma, the negative cold agglutinin titer makes this less likely. | |
pneumococcal pneumonia Hint: In older children the signs and symptoms of pneumococcal pneumonia are similar to an adult and consist of an abrupt onset of cough, fever and chills. The chest x-ray would reveal a lobar consolidation, not interstitial, picture. |
Question 1 Explanation:
The patient's clinical symptoms as well as chest x-ray findings and negative cold agglutinin titer are most consistent with viral pneumonia.
Question 2 |
A previously healthy 3-month-old infant is brought to the emergency department in January with 3 days of nasal congestion, cough, and poor feeding. Temperature is 38.3°C (100.9°F), respiratory rate is 58/min, and oxygen saturation is 93% on room air. Examination reveals diffuse wheezes and crackles, and a chest radiograph shows hyperinflation with patchy interstitial infiltrates. Which of the following is the most likely causative organism?
Adenovirus | |
Influenza A virus | |
Parainfluenza virus | |
Respiratory syncytial virus | |
Rhinovirus |
Question 2 Explanation:
Respiratory syncytial virus (RSV) is the most frequent cause of lower respiratory tract infection (bronchiolitis and viral pneumonia) in infants and young children, characteristically during winter months. It presents with wheezing, tachypnea, and hypoxia. Parainfluenza is the second most common cause; influenza is the most common viral cause of pneumonia overall but is less common than RSV in this age group.
Question 3 |
A 68-year-old man with hypertension and chronic obstructive pulmonary disease presents with 1 day of fever, myalgias, dry cough, and malaise during a documented community influenza outbreak. Temperature is 38.9°C (102.0°F), respiratory rate is 20/min, and oxygen saturation is 95% on room air. A rapid molecular assay is positive for influenza A. Which of the following is the most appropriate pharmacotherapy?
Acyclovir | |
Amantadine | |
Amoxicillin-clavulanate | |
Oseltamivir | |
Ribavirin |
Question 3 Explanation:
Oseltamivir, a neuraminidase inhibitor, is the preferred antiviral for influenza. Benefit is greatest when started within 48 hours of symptom onset, and treatment is recommended for patients at increased risk for complications (e.g., age >65, COPD) regardless of illness duration. Amantadine is no longer recommended because of near-universal adamantane resistance among circulating influenza A strains. Ribavirin (RSV) and acyclovir (herpesviruses) do not treat influenza, and antibacterials such as amoxicillin-clavulanate are not indicated for uncomplicated influenza.
There are 3 questions to complete.
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References: Merck Manual · UpToDate