Upper respiratory tract infection in pediatrics (URTI)

1. Upper respiratory tract infection in pediatrics (URTI)

2. RTI ( respiratory tract infection) IMPORTANCE • Nearly 50% of all paediatric consultations in industrialized countries are caused by respiratory tract infections (RTIs). Acute RTIs are among the leading causes of childhood mortality, especially in developing countries. Their annual incidence per child decreases with age: • 6.1 in children less than 1 year • 5.7 in children aged 1-2 • 4.7 in children aged 3-4 • 3.5 in children aged 5-9 • 2.7 in children aged 10-14 • 2.4 in children aged 15-19.

3. Upper respiratory tract infection (URTI) represents the most common acute illness . Rates are highest in children younger than 5 years. Children who attend school or daycare are a large reservoir for URIs, and they transfer infection to those who care for them. Acute pharyngitis accounts for 1% of all ambulatory visits. The incidence of viral and bacterial pharyngitis peaks in children aged 4-7 years.

4. Rhinopharyngitis • Nasopharyngitis (rhinopharyngitis or thecommoncold) =Inflammation of thenares, pharynx, hypopharynx, uvula, andtonsils • Occur year round, but mostly during fall and winter. Epidemics is most common during cold months, with a peak incidence in late winter to early spring. • Humidity may also affect the prevalence of colds, because most viral URI agents thrive in the low humidity characteristic of winter months

5. Etiology of rhinopharyngitis • Rhinoviruses: These cause approximately 30-50%  • RSV • Coronaviruses: Enteroviruses, including coxsackieviruses, echoviruses, and others: These are also leading causes of the common cold. • Other viruses: Adenoviruses, orthomyxoviruses (including influenza A and B viruses), paramyxoviruses , EBV, account for many URIs. Varicella, rubella, and rubeola • Bacteria ( very rare): streptococci, staph, diphteria, B pertussis, Haemophilus, Pneumococcus, Neisseria, Treponema

6. Risk factors for URIs • Contact: Close contact with small children settings, such as school or daycare, increases the risk of URI. • Travel: , exposure to large numbers of individuals in closed settings. Increased exposure to respiratory pathogens • Environmental factors such as passive smoking and exposure to pollutants • Immunocompromise that affects cellular or humoral immunity: Splenectomy, HIV infection, corticosteroids, immunosuppressive treatment , familial predisposition with immunological defects or anatomical and/or physiological features • Malnutrition • Atopic status • Lack of breast-feeding • Cilia dyskinesia syndrome and cystic fibrosis • Anatomic changes due to facial dysmorphisms • Upper airway trauma, and nasal polyposis • Anemia, rickets, malnutrition • Carrier state

7. Pathophysiology URI • Direct invasion of the mucosa lining the upper airway • Person-to-personspread of viruses by hand with pathogens to the nose or mouth or inhaling respiratory droplets from an infected person who is coughing or sneezing. • Barriers, including physical, mechanical, humoral, and cellular immune defenses. • Hair lining the nose filters • Mucus coats • Ciliated cells lower in the respiratory tract trap and transport pathogens up to the pharynx, where they are then swallowed into the stomach • Adenoids and tonsils contain immune cells that respond to pathogens.

8. local swelling, erythema, edema, secretions, and fever, result from the inflammatory response of the immune system to invading pathogens and from toxins initialnasopharyngealinfectionmayspreadtoadjacentstructures, resulting in sinusitis, otitis media, epiglottitis, laryngitis, tracheobronchitis, and pneumonia Humoral immunity (immunoglobulin A) and cellular immunity Normal nasopharyngeal flora, including various staphylococcal and streptococcal species, help defend against potential pathogens Suboptimal humoral and phagocytic immune function have URI increased risk and have severe or prolonged course of disease.

9. SYMPTOMS OF RF • Nasalobstruction • Congestion of nasal breathing • Sneezing • Rhinorrhea : secretions often evolve from clear to opaque white to green to yellow within 2-3 days of symptom onset • Cough • Anorrhexia • Fever • 5-10 days • Foul breath: This occurs as resident flora process the products of the inflammatory process. • Hyposmia: Also termed anosmia, it is secondary to nasal inflammation. • Headache

10. Sinus symptoms: These may include congestion or pressure and are common with viral URIs. • Photophobia or conjunctivitis: adenovirus . • Influenza : pain behind the eyes, pain with eye movement, or conjunctivitis. • Itchy, watery eyes are common in patients with allergic conditions. • Fever: This is usually slight or absent, but temperatures can reach 39.5°C in infants and young children. If present, fever typically lasts for only a few days. • Gastrointestinal symptoms: Symptoms such as nausea, vomiting, and diarrhea may occur in persons with influenza, especially in children. Nausea and abdominal pain may be present in individuals with strep throat and viral syndromes.

11. LABORATORY • CBC, ES, CRP, to find bacterian infection, Leucocytosis with neutrophilia suggest bacterian, low level of WBC, lymphocytes raised – in viral infections • Because viruses cause most URIs, the diagnostic role of laboratory investigations and radiologic studies is limited. Viral culture, rapid antigen detection, or polymerase chain reaction (PCR) assay of influenza virus on a nasopharyngeal swab could be done if specific antiviral therapy is recommended. Similar tests are also available for adenovirus, respiratory syncytial virus, and parainfluenza virus.

12. The use of reverse-transcriptase PCR for the diagnosis of enterovirus and rhinovirus infections is not currently available for daily clinical care. Serologic tests for mononucleosis Influenza serologiesonly have epidemiologic value and should not be used for clinical care. A pharyngeal swab for rapid antigen detection of GABHS (Group A Beta-HemolyticStreptococci) is 90% sensitive and 95% specific NOSE AND THROAT cultures

13. COMPLICATIONS • Sinusitis is a complication in only approximately 2% of persons with viral URIs • Otitis • Epiglottitis occurs at a rate of 6-14 cases per 100,000 children • Croup, or laryngotracheobronchitis usually occurs in children aged 6 months to 6 years with peak incidence in the second year of life • Pneumonia • Digestive complications: anorrhexia, vomiting, diarrhea, dehidration, • Seizures may appear when fever is more than 38,5 ̊ C

14. Imaging Studies for URTI • A lateral neck radiograph should be taken in a patient with stridor to assess the airways if epiglottitis is clinically suspected • Chest radiography should be reserved for patients with acute tracheobronchitis , those with abnormal vital signs or signs of consolidation on chest examination, or those with persistent symptoms for longer than 3 weeks. • Plain radiography has been largely replaced by computed tomography (CT) in the evaluation of sinusitis, particularly in preparation for corrective surgery. Complete opacification and air-fluid level are the most specific findings for acute sinusitis. • However, a large proportion of patients with the common cold have radiologic abnormalities on CT. Imaging is recommended for patients who do not respond to treatment with antibiotics and decongestants, but is not advised for the diagnosis of uncomplicated sinusitis.Mastoiditis and other intracranial complications of URIs should be evaluated by CT or magnetic resonance imaging.

15. PREVENTION AND TREATMENT • Prevention: VACCINES, IMMUNOSTIMULANTS, VITAMINS • Parent education on risk factor modification, in particular avoiding smoking indoors • General hygiene methods for children attending day care centres • Breast feeding Management • Rest • Lot of fluid intake. • Nasal wash with hypertonic salt water or 0.9% saline • Decongestants to unblock the opening of sinuses and reduce symptoms of nasal congestion in children above 3 years • Paracetamol 30-40 mg/kg/day for fever and pain reliever • Antibiotics to treat the bacterial infection very rare ( fever, ES high, CRP+leucocytosis, children with immune handicaps)

16. ADENOIDITIS Adenoids begin forming in 3rd month of fetal development Coveredbypseudostratifiedciliatedepithelium Fully formed by 7 month Palatine tonsils begin development in 3rdmonth of fetal development

17. Acute adenoiditis ! Symptoms include: – Purulent rhinorrhea – Nasalobstruction – Fever Frequentcomplication: otitismedia Recurrent Acute Adenoiditis ! 4 or more episodes of acute adenoiditis in a 6 month period ! Similar presentation as recurrent acute rhinosinusitis ! In older children nasal endoscopy can help

18. Chronic adenoiditis ! Symptoms include: – Persistent rhinorrhea – Postnasal drip – Malodorous breath – Associated otitis media >3 months – Think of reflux

19. Obstructive AdenoidHyperplasia ! Signs and Symptoms – Obligate mouth breathing – Hyponasal voice – Snoring and other signs of sleep disturbance Obstructive TonsillarHyperplasia ! Snoring and other symptoms of sleep disturbance ! Muffled voice ! Dysphagia

20. Surgery to Remove the Adenoids Adenoids are lymph nodes located high in the back of the throat. They can become enlarged from repeated ear infections and can affect the Eustachian tubes that connect the middle ears and the back of the nose. An adenoidectomy (removal of the adenoids) may help children with recurring ear infections have fewer of them. Adenoidectomy is typically done when recurring ear infections continue despite antibiotic treatment.

21. ACUTE PHARYNGITIS (TONSILITIS) • viral pharyngitis   • Adenovirus, which may also cause laryngitis and conjunctivitis • Influenza viruses • Coxsackievirus • HSV • EBV (infectious mononucleosis) • Cytomegalovirus • causes of bacterial pharyngitis  • Group A streptococci (approximately 15% of all cases of pharyngitis) • Group C and G streptococci • N gonorrhoeae • Arcanobacterium (Corynebacterium) hemolyticum • Corynebacteriumdiphtheriae • Atypical bacteria (eg, M pneumoniae,C pneumoniae): Anaerobic bacteria

22. Immunology and FunctionTONSILS AND ADENOIDS ! Part of secondary immune system ! Exposed to ingested or inspired antigens passed through the epithelial layer ! Immunologic structure is divided into 4 compartments: reticular crypt epithelium, extra follicular area, mantle zone of the lymphoid follicle, and the germinal center of the lymphoid follicle

23. Membrane cells and antigen presenting cells are involved in transport of antigen from the surface to the lymphoid follicle ! Antigen is presented to T-helper cells ! T-helper cells induce B cells in germinal center to produce antibody ! Secretory IgA is primary antibody produced ! Involved in local immunity

24. Acute Tonsillitis Signsandsymptoms: – Fever – Sore throat – Tender cervical lymphadenopathy – Dysphagia – Erythematoustonsilswithexudates

25. Pharyngeal erythema: Marked erythema :adenoviral infection. In contrast, rhinoviral and coronaviral infections do not have severe erythema. Exudates: half the patients with adenovirus infections. Exudativepharyngitis and tonsillitis may be seen with mononucleosis caused by EBV Yellow or green secretions do not differentiate a bacterial pharyngitis from a viral one. Foul breath: This may be noted because resident florae process the products of the inflammatory process.

26. Conjunctivitis -adenovirus. Scleral icterus - infectious mononucleosis. Rhinorrhea - viral cause. Tonsillopharyngeal/palatal petechiae - GAS infections and infectious mononucleosis. A tonsillopharyngeal exudate - streptococcal infectious mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections. exudate does not differentiate viral and bacterial causes. Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus Lymphadenopathy Cardiovascular: Murmurs Pulmonary: Pharyngitis and lower respiratory tract infections with M pneumoniae or C pneumoniae, Abdomen: Hepatosplenomegaly - mononucleosis infection

27. Tonsillar hypertrophy: Peritonsillar abscess may manifest as unilateral palatal and tonsillar pillar swelling, with downward and medial tonsil displacement; the uvula may tilt to the opposite side. Bulging of the posterior pharyngeal wall may signal a retropharyngeal abscess. • Tender anterior cervical adenopathy: This may be present with streptococcal infection or with viral infections. In persons with diphtheria, submandibular and anterior cervical edema may be present along with adenopathy.

28. Erythema: This may be especially prominent in persons with group A streptococcal pharyngitis. Palatal petechiae may be seen. Exudates of the pharynx: These are common with bacterial pharyngitis, manifesting as white or yellow patches. A whitish coating may appear on the tongue, causing the normal bumps to appear more prominent. Yellow or green coloration does not differentiate bacterial pharyngitis from a viral nasopharyngitis.

29. A whitish adherent membrane forming on the nasal septum, along with a mucopurulent blood-tinged discharge, should prompt a consideration of diphtheria. Pharyngeal and tonsillar diphtheria may manifest as an adherent blue-white or gray-green membrane over the tonsils or soft palate; if bleeding has occurred, the membrane may appear blackish.

30. Fever: Compared with other URIs, group A streptococcal infections are more likely cause fever, with temperatures around 38.3°C fever is not reliable to differentiate viral or bacterial etiologies. • Group A beta-hemolytic streptococci: The classic clinical picture includes a fever, tonsillopharyngeal erythema and exudate; swollen, tender anterior cervical adenopathy; headache; emesis in children; palatal petechiae; midwinter to early spring season; and absent cough or rhinorrhea.

31. Conjunctivitis: This symptom may be seen with adenoviral pharyngoconjunctival fever and is present in one half to one third of all adenoviral URIs. Watery, injected conjunctiva may also be seen with allergic conditions. • Cough: This is more suggestive of a viral than a bacterial etiology. • Diarrhea: If associated with a URI, it suggests a viral etiology. • Fever: EBV infections and influenza cause fever.

32. Bacterial pharyngitis • This may be difficult to distinguish from viral pharyngitis. Assessment for group A streptococci warrants special attention. Physical findings that suggest a high risk for group A streptococcal disease are erythema, swelling, or exudates of the tonsils or pharynx; temperature of 38.3°C or higher; tender anterior cervical nodes (>1 cm); and an absence of conjunctivitis, cough, or rhinorrhea, which are suggestive of viral illness.

33. Mucosal ulcers, erosions, vesicles: The presence of palatal vesicles or shallow ulcers is characteristic of primary infection with HSV. • Ulcerative stomatitis may also occur in coxsackievirus or other enteroviral infection. Mucosal erosions may also be seen in primary HIV infection. Small vesicles on the soft palate, uvula, and anterior tonsillar pillars suggest infection by coxsackievirus, known as herpangina. Tonsillar hypertrophy Foul breath: Halitosis may be noted because resident florae process the products of the inflammatory process. Anterior cervical lymphadenopathy: This is seen with viral and bacterial infections. Approximately half of EBV mononucleosis cases involve generalized adenopathy or splenomegaly. An enlarged liver may also be palpable. Primary HIV infection may also include lymphadenopathy.

34. A rash may be seen with group A streptococcal infections, particularly in patients younger than 18 years. This scarlet fever rash appears as tiny papules over the chest and abdomen, creating roughness like sunburned appearance. The rash spreads, causing erythema in the groin and armpits. The face may be flushed, with pallor around the lips. Approximately 2-5 days later, the rash begins to resolve. Peeling is often noted on the tips of toes and fingers

36. COMPLICATIONS • In the neighbourhood: • Adenitis • Retropharyngeal abscess • Peritonsilar abcess • Otitis • Sinusitis ( epiglotitis) • At distance: •  acute glomerulonephritis, acuterheumatic fever, and rheumatic heart disease • toxic shock syndrome for GAS ( group A Streptococcus )

37. Recurrent Acute Tonsillitis ! Same signs and symptoms as acute ! Occurring in 4-7 separate episodes per year ! 5 episodes per year for 2 years ! 3 episodes per year for 3 years

38. Medical Management ! Penicillin is first line treatment ! Recurrent or unresponsive infections require treatment with beta-lactamase resistant antibiotics such as Erytromycin, Claritromycin Clindamycin Augmentin: 30-40 mg/kg in 2 doses. Syrup, tablets Cephalosporins ( Ist and II gen)

39. Tonsillectomy ! Current clinical indicators : – 3 or more infections per year despite adequate medical therapy – Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by orthodontist – Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorder, cardiopulmonary complications

40. Peritonsillar abscess ! Abscessformationoutsidetonsillar capsule ! Signsandsymptoms: – Fever – Sore throat – Dysphagia/odynophagia – Drooling – Trismus – Unilateral swelling of soft palate/pharynx with uvula deviation

41. Peritonsillar abscess Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage – Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy – Chronic or recurrent tonsillitis associated with streptococcal carrier state and not responding to betalactamase resistant antibiotics – Unilateral tonsil hypertrophy presumed neoplastic

42. Chronic Tonsillitis ! Chronic sore throat ! Malodorous breath ! Presence of tonsilliths ! Peritonsillar erythema ! Persistent tender cervical lymphadenopathy ! Lasting at least 3 months

43. OTITIS MEDIA • The eustachian tubes equalize the pressure between the middle ear cavity and the outside atmosphere and allow fluid and mucus to drain out of the middle ear cavity. Inflammation of the middle ear causes the tubes to close causing the fluid to become trapped. Bacteria from the back of the nose travel through the eustachian tube directly into the middle ear cavity and multiply in the fluid. The inflammation can occur as a result of an infection extending up the eustachian tube. This tube may become blocked by a bacterial or viral infection or by enlarged adenoids. Fluid produced by the inflammation cannot drain off through the tube and instead collects in the middle ear.

44. The Eustachian tube is a canal that connects the middle ear to the throat. It is lined with mucus, just like the nose and throat; it helps clear fluid out of the middle ear and into the nasal passages. Cold, flu, and allergies can irritate the Eustachian tube and cause the lining of this passageway to become swollen.

45. Ear Infection diagnose an ear infection by looking at the outer ear and the eardrum with a device called an otoscope. A healthy eardrum (shown here) appears transparent and pinkish-gray. An infected eardrum looks red and swollen.

46. If the Eustachian tube becomes blocked, fluid builds up in the middle ear. This creates an environment for bacteria and viruses, which can cause infection; fluid is detected in the middle ear with a pneumatic otoscope. This device blows a small amount of air at the eardrum, making the eardrum vibrate. If fluid is present, the eardrum will not move as much as it should.

47. Ruptured Eardrum When too much fluid builds up in the middle ear, it can put pressure on the eardrum until it ruptures (shown here). Signs of a ruptured eardrum include yellow, brown, or white fluid draining from the ear. Pain may disappear suddenly because the pressure of the fluid on the eardrum is gone. Although a ruptured eardrum sounds frightening, it usually heals itself in a couple of weeks.

48. SIGNS AND SYMPTOMS Ear Infection Symptom Sudden, piercing pain in the ear which may be worse when lying down, making it difficult to sleep. Trouble hearing. A fever of up to 40 ̊ C . Tugging or pulling at one or both ears. Fluid drainage from ears. Loss of balance. Nausea, vomiting, or diarrhea. Congestion. Ear Infection Symptoms: Babies It can be difficult to identify an ear infection in babies or children :crankiness, trouble sleeping, and loss of appetite. Babies may push their bottles away because pressure in the middle ear makes it painful to swallow.

49. Laboratory • WBC, ES, Fg, CRP, high if bacterian • Local exam with otoscope • Cultures of otic discharge • Imagery when progresses through otomastoiditis

50. COMPLCATIONS • CRONIC OTITIS • OTOMASTOIDITIS • DEAFNESS • CEREBRAL VENOUS TROMBOSIS • CEREBRAL ABCESS • MENINGITIS • DIARRHEEA, DEHIDRATION • SEIZURES