PANCE Blueprint Pulmonary (10%)

Viral pneumonia

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 bilateral interstitial infiltrates and a cold agglutinin titer that is negative. Examination reveals scattered rhonchi and rales upon auscultation of the chest.

AdultsThe 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
CXR showing typical findings of bilateral interstitial infiltrates

CXR showing typical findings of bilateral interstitial infiltrates

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
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
While the gradual onset of symptoms suggest mycoplasma, the negative cold agglutinin titer makes this less likely.
pneumococcal pneumonia
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.
There is 1 question to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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