CASE  1

The patient was a 4-month-old female with congenital heart disease who was admitted to the hospital in January with severe respiratory distress. Five days prior to admission she had developed a cough and rhinitis. Two days later she began wheezing and was noted to have a fever. She was brought to the emergency room when she became lethargic.

One sibling was reported to be coughing, and her father had a "cold". On examination she was agitated and coughing. She had a fever of 38.90C, tachycardia with a pulse of 220, tachypnea with respirations of 80/min., and a blood pressure of 90/58 mm Hg. Her fontanelles were open, soft, and flat. Her throat was clear. She had subcostal retractions and nasal flaring. On auscultation of her lungs, there were rhonchi as well as inspiratory and expiratory wheezes.

A chest radiograph revealed interstitial infiltrates and hyperexpansion. Arterial blood gases on supplemental oxygen revealed respiratory acidosis with relative hypoxemia. She was put in respiratory isolation in the pediatric intensive care unit and was subsequently intubated. Blood and nasopharyngeal cultures were obtained and sent to the bacteriology and virology laboratories. A nasopharyngeal wash specimen was positive for RSV antigen by rapid test and specific antiviral therapy was begun. She was extubated 5 days later and discharged home on day 8.

BACKGROUND

This patient was found to be infected with RSV (a negative strand RNA virus), which causes severe infections in children less than 1 year old, whereas re-infections in older children and adults may result in minimal respiratory tract symptoms. RSV can also cause acute laryngotracheobronchitis. The elderly may also develop severe RSV infections.

The differential diagnosis for this patient's pneumonia includes respiratory viruses such as parainfluenza virus types 1, 2 and 3, influenza A and B viruses, and respiratory syncytial virus (RSV).  Bordetella pertussis could also have caused her illness.

Case 1

  1. What type of isolation should the patient be put in?  

  2. What is known about the pathogenesis of the infection?  

  3. Describe the rapid test used for detection of RSV.  

  4. A formalin fixed-killed virus vaccine was tested against RSV. Why was this vaccine discontinued? 

  5. Describe the preventative therapy currently in use for selected infants.  

  6. Is this child likely to be reinfected?