An overview of bacterial and viral

infections of the upper respiratory

tract.Injury to mucociliary apparatus
3rd March.2015.Physiology module
Dr Jalees Khalid Khan
Pathology Deptt. KEMU. Lahore

Upper respitaory
infections
Upper respiratory tract
infections are the most
common human
affliction.
Major share of time lost
from work and school.
Most common cause of
antibiotic abuse.

Figure 21.1

Normal flora of respiratory tract

Generally limited to the upper respiratory tract

Gram-positive bacteria (streptococci and
staphylococci) very common
Disease-causing bacteria are present as normal
biota; can cause disease if their host becomes
immunocompromised or if they are transferred
to other hosts (Streptococcus pyogenes,
Haemophilus influenza, Streptococcus
pneumonia, Neisseria meningitides,
Staphylococcus aureus)
Normal biota perform microbial antagonism

Respiratory tract

Most common place for infectious agents to gain access to

the body

Upper respiratory tract: mouth, nose, nasal

cavity, sinuses, pharynx, epiglottis, larynx

Lower respiratory tract: trachea, bronchi, bronchioles,

lungs, alveoli
Defences

Nasal hair
Cilia
Mucus
Involuntary responses such as coughing, sneezing, and swallowing
Macrophages
Secretory IgA against specific pathogens

Diseases
Influenza
Epiglottitis
Sinusitis
The

Common Cold
Diphtheria

The significance in relationship

with antibiotic abuse
Nosocomial infections-indisciminate use of
drugs by doctors and quacks.
Drug resistance-causes
Cell wall alteration, Plasmid, ESBL,Efflux
pump etc
Lysogenic strains
MRSA and others

Epidemiology
Pandemics
Worldwide - antigenic
shift
Epidemics
Local - antigenic drift
Endemic
Sporadic
Seasonal
Winter months - abrupt
Age
Infection: children
>adults
Mortality: adults
>children

Pathogenesis

Virus replication: 24 - 72 hours

Virus excretion: 3 - 7 days

Antibodies to HA, NA subtypes

Secondary bacterial
pathogens

S. pneumoniae

H. influenzae

S. aureus - Toxin Shock Syndrome

Reyes syndrome
Post influenza B
Encephalopathy
Hepatic dysfunction
Elevate NH3, LFTs, CPK
Children:Streptococcus pneumoniae

Most common cause outside of neonatal period

Nasopharyngeal colonization 50% of kids
>90 serotypes majority of invasive disease caused by 10
serotypes
Bacteremia in 25-30% of kids
Gram stain gram positive lancet shaped diplococci (gram
positive cocci in pairs)

Age differences

Adults lobar pneumonia

Kids lobar or bronchopneumonia

Diagnosis
Classically a lobar consolidation on CXR
Raise suspicion of staph

Pneumatoceles
Pleural effusion
Air fluid levels
Necrosis

The effect of cigarette smoke or gaseous

inhalation on respiratory tract

Changes in alveolar epithelial-ciliated

columnar to pseudostratified/columnar
epithelium
Inefficiency of cilia to expel the
debris,contaminants,carbon etc inhaled
from atmosphere
Emphysema, COPD,
Bronchiectasis,Carcinoma of lung

Influenza Vaccine

Trivalent vaccine
A/Beijing/262/95-like
(H1N1)
A/Sydney/5/97-like
(H3N2)
B/Harbin/07/94

Indications for Vaccine

Elderly (age>65)
High-risk*
Household contacts
Health-care personnel
Pregnant women after 14th week

High-risk: institutionalized, chronic heart or

lung disease, diabetes,
renal dysfunction, immunosuppressed,
children on aspirin

The significance of
vaccination,the target groups
that should be vaccinated,
Killed vaccines
frequency
and side effects

Live vaccines
Live vaccines are long acting while short acting are
killed vaccines
Immunization

Measles

Pneumonia is what they die of often super-infection

World-wide coverage rate 76% in 2004
Still having 30-40 million cases a year

HemophilusInfluenzae B

2-3 million cases of severe disease a year

In 2003, developed world coverage 92%
Developing world 42%
Least developed countries 8%

Influenza Vaccine

Timing: October Mid-November

Duration of
immunity:
start 1-2 weeks
end 4-6 months

Side effects
Prozone phenomenon
Serum sickness
Fever, lymphadenopathy
Severe anaphylactic reation
Defective vaccine production-NIH
DPT-not properly killed

Diagnosis
*Viral culture tissue
culture
*Fluorescent-labeled
murine monoclonal Ab shell viral cell culture viral Ag
*PCR
*CF - at onset and 2
weeks
4-fold-rise in Ab titre

Prophylaxis of Influenza A
Control of outbreaks in institutions
Adjunct to late vaccination
Immunodeficient - AIDS
Vaccine contraindicated
Home caregivers of high risk

Epiglottitis

Epidemiology:
most common in children 3-7 yrs.
decreased incidence because of Hib conjugate
vaccine-stable rate in adults

Rate:
1 in 1000-2000 pediatric admissions
1 in 100,000 adult admissions

D/Diagnosis

Peritonsillar abscess
sore throat, drooling, hoarseness, trismus, asymmetric
tonsillar enlargement

Epiglottitis
Children: high fever, toxic, drooling, absence of cough
Adult: severe sore throat, dyshagia, fever

Infectious mononucleosis
tonsillar enlargement, exudative tonsillitis, pharyngeal
inflammation, lymphadenopathy, splenomegaly,
maculopapular rashes, petechial anathema

Parapharyngeal space infection

neck swelling after a sore throat

Epiglottitis - Pathogenesis
Haemophilus influenzae type b,
S. pneumoniae, S. aureus, H. influenzae
type non-b, H. parainfluenzae
Inflammation and edema of the epiglottis,
arytenoids, arytenoepiglottic folds,
subglottic area
Epiglottis pulled down into larynx and
occludes the airway

Epiglottitis - Pathogenesis

Visualization of epiglottis - cherry red

Laternal neck x-rays: thumb sign
WBC count > 15,000 left shift
Blood cultures
Prophylaxis: Rifampin - 20 mg/kg for 4 days
All household contacts if children under 4
Daycare and nursery school contacts
Patient before discharge

Sinusitis-clinical signs
*Viral URI, fever (50%),
purulent nasal discharge,
swelling, facial pain worse
on percussion, headache,
nasal obstruction, loss of
smell
*Children: facial pain,
swelling, malodorous breath
(50%), cough (80%), nasal
discharge (76%), fever
(63%), sore throat (23%)

Diagnosis
Nasal swabs not helpful
Transillumination of maxillary and frontal
sinuses
Sinus x-rays: air-fluid level, complete
opacity, mucosal thickening
CT scan not indicated - unless chronic
infection, immunocompromised, suspected
intracranial or orbital complication
Direct sinus aspiration

Factors predisposing to
sinusitis
Impaired

mucociliary function
Obstruction of sinus ostia
Immune defects
Increased risk of microbial
invasion

Microbial causes
PREVALENCE MEAN (RANGE)
Adults Children
MICROBIAL AGENT (Bacteria)
(%)
(%)
Streptococcus pneumoniae 31 (20-35)
36
Haemophilus influenzae 21 (6-26)
23
(nonencapsulated)
S. pneumoniae and H. influenzae 5 (1-9)
-Anaerobes (Bacteroides, Fusobacterium, 6 (0-10)
Peptostreptococcus, Veillonella)
Staphylococcus aureus 4 (0-8)
-Streptococcus pyogenes 2 (1-3)
2
Branhamella (Moraxella) catarrhalis 2
19
Gram-negative bacteria 9 (0-24)
2
Fugal causes in immunocompromised

--

Microbial causes
PREVALENCE MEAN (RANGE)
Adults Children
MICROBIAL AGENT (%)
(%)
Viruses
Rhinovirus 15
-Influenza virus 5
-Parainfluenza virus 3
2
Adenovirus
-2

Complications of Sinusitis
Complication

Clinical Signs

MeningitisHeadache, fever, stiff neck lethargy, rapid

death
Osteomyelitis Potts puffy tumor
Epidural abscess Headache, fever
Subdural empyema Headache, seizures
hemiplegia, rapid death
Cerebral abscess Convulsions, headache, personality
change
Venous sinus thrombosis Picket-fence fever, rapid
death
Cavernous sinus Orbital edema, ocular palsies

Virology
Over 200 viruses
Virus type

Serotypes

Andenoviruses
41
Coronaviruses
2
Influenza viruses
3
Parainfluenza viruses
4
Respiratory syncytial virus
1
Rhinoviruses
100+
Enteroviruses
60+

Seasonal variation
May-Aug - Enteroviruses
Sept-Dec - Mycoplasma, Rhinoviruses,
Parainf. 1+2, RSV
Jan-Feb - Adenoviruses, Influenza,
Coronaviruses
Mar-Apr
- Parainf. 3, Rhinoviruses

Transmission
Direct contact with infected secretions
Hand - to - hand
Hand - to environmental surface - to hand
Spread by aerosoles
Complications:Bacterial superinfection

Otitis media
Sinusitis
S. pneumoniae, H. influenzae, B. catarrhalis

Guillain-Barre Syndrome
Asthma attacks

Aspirin and influenza

Aspirin - prolonged excretion of rhinoviruses,

influenza virus

Children - aspirin associated with Reyes

syndrome
Prevention:Vaccines

influenza A/B
adenoviruses types 4,7

Intranasal interferon
rhinoviruses
nasal obstruction, bloody discharge