Inpatient Viral Infections: Which Ones Should We Think About, Test - - PDF document

10/26/2015 1

Inpatient Viral Infections: Which Ones Should We Think About, Test For, and Treat

Jennifer Babik, MD, PhD Assistant Clinical Professor Division of Infectious Diseases, UCSF

Management of the Hospitalized Patient October 2015 Disclosures

• I have no disclosures.

10/26/2015 2

Learning Objectives

• 1. To recognize the key clinical features of the most

common viral infections encountered in hospitalized patients.

• 2. To develop a framework for diagnosis and

management of common inpatient viral infections.

Viruses Covered

• Herpesviruses
• CMV
• HSV
• VZV
• Respiratory viruses
• Influenza
• Other respiratory viruses

10/26/2015 3

Case #1

47 year old M with no PMH is admitted with fever and respiratory distress. CT shows prominent GGO. HIV Ab test is positive and CD4 is 56. BAL is performed and is positive for PCP. BAL is also positive for CMV

• culture. Plasma CMV PCR is

positive at 970 IU/mL.

What Antibiotics Should You Start?

• 1. TMP‐SMX alone
• 2. TMP‐SMX plus ganciclovir
• 3. TMP‐SMX plus acyclovir
• 4. TMP‐SMX plus IVIG

10/26/2015 4

Approach to CMV Infections: Define the Host

Immunocompetent

• Primary infection
• Clinical
• Usually asymptomatic
• Heterophile (‐) mononucleosis
• Case reports of severe disease
• Diagnosis
• Serology > PCR
• Usually self‐limiting, no Rx

Immunocompromised

• Primary or reactivation
• Clinical
• Asymptomatic viremia
• CMV syndrome
• End‐organ disease
• Diagnosis
• Serology not helpful
• Tissue biopsy >> culture
• Blood PCR
• Usually requires treatment

Navalpotro et al, J Clin Virol 2006; 35:193. Wreghitt et al, Clin Infect Dis 2003; 37:1603.

CMV Infection in Immunocompromised Patients

Asymptomatic Viremia Asymptomatic Plasma CMV PCR (+) Decision to treat depends on viral load and host; may just follow levels CMV Syndrome Fever plus bone marrow suppression (leukopenia and/or thrombocytopenia) Plasma CMV PCR (+) Treat all patients End‐Organ Disease

• Neuro: Encephalitis,

Retinitis, Polyradiculopathy

• Pneumonitis
• GI: Colitis>Esophagitis
• Others: hepatitis, nephritis,

myocarditis, pancreatitis Plasma CMV PCR (+) (except GI disease can be compartmentalized) Treat all patients

CMV Infection

10/26/2015 5

CMV in HIV vs Transplant

HIV

• Host:
• End‐organ disease in CD4<50
• Most common presentations:
• Asymptomatic viremia common

(15‐35% pts w/CD4<200)

• Retinitis
• GI (colitis > esophagitis)
• Pneumonitis is rare: BAL+ for

CMV in ~50% of patients with

• ther respiratory OIs

Transplant

• Host:
• SOT and HSCT
• Also patients taking high levels
• f immunosuppressives or

steroids (e.g. rheum patients)

• Most common presentations:
• Asymptomatic viremia
• CMV syndrome
• Pneumonitis
• Colitis

Durier et al, Clin Infect Dis 2013;57:147. Deayton et al, Lancet 2004; 363: 2116. Hayner et al, Chest 1995;107;735. Miles et al, Chest 1990;97;1072. CDC/NIH/HIVMA Guidelines for the prevention and treatment of OIs in HIV‐infected adults, 2015.

CMV End‐Organ Disease

CMV Colitis

• Fever, diarrhea (+/‐ bloody), abd pain
• Dx by colonoscopy with path, IHC
• Blood PCR can be negative

CMV Pneumonitis

• Fever, mild to severe resp failure
• CT shows diffuse bilateral GGO
• Dx by BAL: culture, path
• Blood PCR usually positive

10/26/2015 6

CMV Treatment

• IV vs PO?
• IV ganciclovir for severe EOD, high VL, concerns re: oral absorption
• PO valganciclovir okay for mild‐moderate disease (VICTOR trial)
• IVIG?  Case‐by‐case basis for severe disease (pneumonitis)
• How long to treat?
• 2‐3 weeks and until PCR negative
• Consider secondary ppx in selected patients
• PCR monitoring?
• Check 2 wks after starting rx (VL may stay the same or  in 1st wk)
• Then check qweek until negative

Razonable et al, Am J Transplant 2013; 13:93. Asberg et al (VICTOR study group), Am J Transplant 2007; 7:2106.

Case #1 Continued

The patient was treated for PCP and started on ARVs. He was not treated for CMV. 3 weeks later he represents with fever but no other localizing signs or symptoms. Labs:

• WBC 1.0, platelets 81 (both previously normal)
• CMV viral load in the plasma is now 226,091 IU/mL.

10/26/2015 7

Review question: What is the diagnosis?

• 1. Asymptomatic CMV viremia
• 2. CMV syndrome
• 3. CMV end‐organ disease

CMV: Take‐Home Points

• Define your host: immunocompetent or

immunocompromised (HIV vs transplant/other)

• Determine which type of CMV infection your patient has:
• Asymptomatic viremia
• CMV syndrome
• End‐organ disease
• HIV+ patients are a special category:
• Commonly have asymptomatic viremia
• Can have severe end‐organ disease (retinitis, GI most common)
• Rarely have pneumonitis despite frequent +BAL for CMV

10/26/2015 8

Case #1 Continued

The patient now tells you he has been having severe mouth pain. Oral exam shows significant ulcerations on his tongue and angular cheilitis. You are concerned about CMV vs HSV.

The most sensitive test for HSV is this situation is:

• 1. Ulcer swab for HSV DFA
• 2. Ulcer swab for HSV culture

10/26/2015 9

Diagnosis of Mucocutaneous HSV

Lesion swab HSV Culture Vesicle 70‐90% Ulcer 30‐40% Crusted 20‐30% More sensitive than DFA PCR Overall 90% Best test if available DFA Vesicle 70‐90% Ulcer 30% Crusted 10% More rapid than culture

Case #2 Continued

• Oral ulcer swab:
• HSV DFA QNS
• HSV culture +HSV‐1
• Due to concurrent CMV, he was

treated with IV ganciclovir then

• ral valganciclovir to complete

4 weeks.

• After 1 week, CBC normalized

and oral ulcers completely resolved.

10/26/2015 10

Antivirals Against Herpesviruses

Antiviral HSV VZV CMV EBV Acyclovir Valacyclovir Famciclovir

++ ++ + +

Ganciclovir Valganciclovir

++ ++ ++ ++

Case #2

55 year old man is brought in by his neighbor for bizarre behavior for 12

• hours. He is found to be febrile and

has a witnessed seizure in the ED. MRI is shown. He is started on vancomycin, ceftriaxone, and acyclovir and is tapped 24 h later. Lumbar puncture:

• 50 WBC (89% lymphs), 50 RBC,

protein 80, glucose 78.

• CSF culture is NGTD
• PCR is negative for HSV and VZV.

10/26/2015 11

Your Next Management Step Would Be:

• 1. D/C acyclovir
• 2. Continue acyclovir
• 3. Add ampicillin
• 4. Add ganciclovir

You Think The HSV PCR May Be Negative B/C:

• 1. He got 24 hours of acyclovir
• 2. It’s not a sensitive test
• 3. It’s early in the disease course

10/26/2015 12

HSV Encephalitis

• Epidemiology:
• Bimodal: 1/3 of cases <20 years old, 1/3 cases >50 years old
• Accounts for 10‐20% of encephalitis
• Microbiology:
• >90% due to HSV‐1, most are due to reactivation
• HSV‐2 rare, more common in immunocompromised patients
• Clinical:
• Frontal and temporal lobes affected
• Fever, personality changes, aphasia, seizures, focal weakness

HSV Encephalitis: CSF Profile

• Classic profile:
• WBCs: lymphocytic pleocytosis (median 130 cells/mm3)
• RBCs: elevated (usually <500)
• Protein: elevated (median 80 mg/dl)
• Glucose: normal
• CSF does not always have RBCs or WBCs:
• RBCs normal in 15%
• WBC normal in 4‐15%

Whitley et al, JAMA 1982, 247:312. Whitley et al, JAMA 1989, 262:234. Tang et al, Clin Infect Dis 1999, 29:803. Domingues et al, Clin Infect Dis 1997, 25:86.

10/26/2015 13

HSV Encephalitis: Diagnosis and Rx

• CSF PCR:
• 96% sensitive, 99% specific
• May have false (‐) in the first 3d  if suspicion is high re‐tap
• ACV has little effect on PCR (+) within the first 5 days of therapy
• MRI: temporal lobe abnormalities in 90%
• Treatment:
• ACV 10mg/kg IV q8h x 14‐21 days
• Consider checking an HSV PCR at day 14 to define duration

DeBiasi and Tyler, Clin Microbiol Rev 2004, 17:903. Tyler, Herpes 2004, 11 Suppl 2: 57A

HSV Aseptic Meningitis

• 1st episode in 1˚ genital HSV‐2 (women>men)
• Recurrent aseptic meningitis:
• 20‐30% of patients will have at least 1 recurrence
• Mollaret’s meningitis = repeated self‐limiting

episodes, with or without recurrent skin lesions

• Treatment:
• Role of antivirals not clearly defined: can consider

ACV 10 mg/kg q8h or valacyclovir 1gm PO tid x 7‐14d

• May be of benefit in immunocompromised patients
• Suppressive rx not effective to prevent recurrences

Tyler, Herpes 2004, 11 Suppl 2: 57A. Aurelius et al, Clin Infect Dis 2012, 54: 1304. Berger and Houff, Arch Neurol 2008, 65:596. Sendi and Graber, CMAJ 2006, 174:1710. Noska et al, Clin Infect Dis 2015;60:237.

10/26/2015 14

HSV Neuro Complications: Take‐Home

• HSV encephalitis is usually caused by HSV‐1 and

affects the frontal/temporal lobes

• CSF HSV PCR is very sensitive for HSV encephalitis:
• There can be false (‐) within the first 3 days of symptoms
• ACV has little effect on sensitivity within the first 5 days
• HSV meningitis is a complication of primary genital

herpes from HSV‐2 and can be recurrent

Case #3

64 year old man presents with a blistering painful rash

• n his left leg in the L4 and L5

dermatomes. He is started on acyclovir but still has new lesions on his shin after 24 hours.

10/26/2015 15

The Most Likely Diagnosis Is:

• 1. Disseminated zoster
• 2. Resistant zoster
• 3. Uncomplicated herpes zoster

Zoster: Key Clinical Features

• 80% have prodrome preceding lesions by 2‐

3 days

• New vesicles appear for 2‐4 days (antivirals

 new lesion formation by 1‐2 days)

• Overlap into adjacent dermatomes in 20%

(normal variation in innervation)

• PHN: pain lasting >3 months after zoster

episode, occurs in 10‐20%

Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.

10/26/2015 16

To confirm the dx, the most sensitive test is:

• 1. VZV DFA
• 2. VZV culture

Diagnosis of VZV

Lesion swab VZV Culture Sensitivity 60‐75% Specificity 100% Takes 1‐2 weeks to grow Not usually performed PCR Sensitivity 95% Best test if available DFA Sensitivity 90% Specificity 95% Rapid (hours) Test of choice in most places

10/26/2015 17

Review: Diagnosis of HSV vs VZV

Lesion swab HSV VZV Culture

+ ‐‐

DFA

+ +

PCR

+ +

Which is the Best Choice to  the Risk of PHN?

• 1. Prednisone
• 2. Valacyclovir
• 3. Valacyclovir and prednisone

10/26/2015 18

Zoster Treatment: Antivirals

• Benefits of therapy
•  duration of viral shedding and new lesion formation (by 1‐2d)
•  severity and duration of acute pain and rash
• Most (but not all) studies show a  risk of PHN (by inhibiting viral

replication and neural damage)

• Who to Treat?
• ≥50 years of age
• Moderate or severe pain or rash
• Nontruncal involvement
• Immunocompromised
• But consider treating EVERYONE even with mild disease as the

benefit (preventing PHN) likely outweighs risk (drugs are safe)

Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1. Chen et al, Cochrane Database Syst Rev 2010; Issue 12.

Timing of Therapy

• Timing:
• All RCTs initiate therapy within 72 hours
• Starting therapy at >72h hasn’t been well studied, but it is

possible there may be some benefit up to 7d

• If a patient presents at >72 hrs, consider treating if:
• Presence of new vesicles (indicating viral replication)
• Cutaneous, motor, ocular, neurologic complications
• Advanced age, severe pain (since these are RF for PHN)
• Immunocompromised

Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.

10/26/2015 19

Zoster: Antiviral Regimens

• Drug options
• Acyclovir 800 mg 5 times daily for 7–10 days
• Famciclovir 500 mg tid daily for 7 days
• Valacyclovir 1000 mg tid daily for 7 days
• For immunocompromised patients:
• Treat until all lesions have crusted given the risk of

relapse (this may take longer than 7‐10 days)

Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1.

Steroids in Acute Zoster

• Studies
• 3 RCTs: ACV+steroids vs ACV+placebo within 72‐96h of onset
• The addition of steroids to ACV:
• Accelerated healing and reduced acute pain (by ~1.5‐3 fold)
• Improved quality of life
• But no decrease in PHN
• So when to consider steroids?
• Moderate to severe pain
• Facial nerve paralysis
• Ocular VZV with significant edema
• No contraindications to steroid use
• Regimen: Prednisone 60 mg/d then taper over 10‐21 d

Wood et al, N Eng J Med 1994; 330:896. Whitley et al, Annals Int Med 1996; 125:376. Esmann et al, Lancet 1987; 330:126. Chen et al, Cochrane Database Syst Rev 2010; Issue 12.

10/26/2015 20

Case #4

75 y/o man with HTN, CAD presents to clinic with a rash

• ver his R eye in the V1

distribution associated with conjunctival injection.

How Would You Treat Him?

• 1. High dose PO valacyclovir and close follow‐up
• 2. Admission and IV acyclovir

10/26/2015 21

VZV Ophthalmicus

• Defined as zoster in the V1 distribution
• Without treatment, 50% will develop ocular

complications

• Conjunctivitis
• Anterior uveitis
• Necrotizing retinitis
• Keratitis
• Corneal ulcer
• Orbital apex syndrome

Harding et al, Br J Ophthalmol 1987.

VZV Ophthalmicus: Management

• Ophtho consult
• For all patients with eye symptoms, with lesions on the tip or

side of the nose, or who are immunocompromised

• Antivirals:
• All patients should be treated irrespective of the duration of

symptoms

• Treat with intravenous ACV in immunocompromised patients or

with eye involvement

• Consider systemic steroids if there is significant edema, which

can cause orbital apex syndrome via pressure on nerves entering the orbit

Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1

10/26/2015 22

Case #5

A 59 year old man with SLE

• n cellcept and prednisone

(10 mg/day) presents with diffuse vesciular rash. VZV DFA is positive.

How Would You Treat Him?

• 1. High dose PO valacyclovir and close follow‐up
• 2. Admission and IV acyclovir

10/26/2015 23

Complicated Zoster

• Disseminated Zoster
• Neurologic Complications
• Aseptic Meningitis
• Encephalitis (small vessel vasculopathy)
• Stroke (large vessel vasculopathy)
• Transverse Myelitis
• Ocular involvement

Disseminated VZV

• = lesions outside the the

primary or adjacent dermatomes

• Usually in

immunocompromised, occurs via viremic spread to the skin

• Patients may have new lesions

for up to 2 weeks

• Patients are at high risk for

pneumonitis, hepatitis, DIC

Cohen, NEJM 2013, 369:255.

10/26/2015 24

VZV Encephalitis

• Usually occurs in immunocompromised patients
• Clinical:
• HA, fever, AMS, seizures
• Rash can be absent (in up to 1/3)
• CSF profile:
• Lymphocytic pleocytosis (median 110 cells/mm3)
• Elevated protein (median 260 mg/dL)
• Glucose normal to slightly low (median 55 mg/dL)
• Positive VZV PCR (sensitivity 80‐100%, specificity 98%)
• Positive VZV IgG (more sensitive than PCR for chronic cases)

Gilden et al, NEJM 2000. Pahud et al, J Infect Dis 2011, 203:316.

Treatment of Complicated Zoster

• When to admit patients for IV acyclovir?
• Disseminated disease or CNS complications
• Severely immunocompromised patients with localized

disease (to prevent dissemination)

• Strongly consider in VZV Ophthalmicus
• How long to treat and when can you switch to PO?
• Total duration 2‐3 weeks
• Use IV for at least 7 days (and until all lesions are crusted)
• Can switch to PO valacyclovir on a case by case basis

Pergam et al, Am J Transplantation 2013. Dworkin et al, Clin Infect Dis 2007; 44 (Suppl1): S1

10/26/2015 25

VZV: Take Home Points

• DFA (or PCR) is the diagnostic method of choice for

cutaneous zoster

• Antivirals decrease symptom severity and duration, and

may have some benefit in  risk of PHN

• Steroids provide no additional benefit in  risk of PHN
• Admit patients for IV acyclovir if they have disseminated

disease, CNS complications, or are severely immunocompromised

Case #6

A 35 year old man is admitted in January with 5 days of fever, cough and progressive respiratory distress. He rapidly deteriorates and is

• intubated. Rapid influenza

antigen test in the ED is negative.

10/26/2015 26

What is the Sensitivity of the Rapid Antigen Tests?

• 1. 10‐30%
• 2. 50‐70%
• 3. >90%

Diagnostic Tests for Influenza

Rapid Antigen Testing

• Point‐of‐care tests
• Widely available in clinics

and ERs

• ~50‐70% sensitive
• >90% specific
• Cannot be used to exclude

influenza during flu season Molecular Assays

• ~95% sensitive and specific
• Test of choice
• Some assays can

determine:

• Influenza A vs B
• Influenza A subtypes

(seasonal H1N1, seasonal H3N2, pandemic H1N1)

Harper et al, Clin Infect Dis 2009, 48:1003. CDC, Influenza Symptoms and the Role of Laboratory Diagnostics, 2011.

10/26/2015 27

Diagnosis: Samples

• Upper tract samples:
• NP swabs or aspirates
• Collect samples preferably within 5 days (as shedding is

 after 5d)

• In critically ill patients: collect both upper and lower

tract specimens

• Lower tract samples can be positive even if viral shedding

is no longer detectable in the upper tract

• If suspicion is high, do not stop empiric therapy until lower

tract sample is negative

Harper et al, Clin Infect Dis 2009, 48:1003. CDC, Influenza Symptoms and the Role of Laboratory Diagnostics, 2011.

Case #6 Continued

He gets an NP swab influenza PCR assay and the sample is positive for influenza A.

10/26/2015 28

Would You Give Him Antivirals?

• 1. No antivirals (he is out of the treatment window)
• 2. Oseltamivir 75mg PO bid x 5 days
• 3. Oseltamivir 150mg PO bid x 10 days
• 4. Zanamavir 10mg inhaled bid x 5 days

M2 Inhibitors

• Amantadine, rimantidine
• Influenza A only
• Widespread resistance

Matrix proteins (M1 and M2)

Antivirals

Neuraminidase Inhibitors

• Oseltamivir, Zanamivir, Peramivir
• Influenza A and B
• Drugs of choice

X

10/26/2015 29

Neurominidase Inhibitors

Drug Adult dosage Can use if intubated? Contra‐ indications Adverse Effects Oseltamivir 75mg PO bid x 5 d Yes None Nausea/vomiting Zanamivir 10mg INH bid x 5 d No Underlying resp disease (asthma, COPD) Bronchospasm, cough Peramivir 600mg IV x 1 Yes None Diarrhea

Timing of Oseltamivir in Inpatients

• Treatment of inpatients within 48hrs of symptom onset:
•  mortality by 50‐65%
• But >40% of patients hospitalized with influenza present at >48 h
• Multiple studies have shown a mortality benefit for

treating inpatients at >48hrs:

• Treatment seems to be effective even out to 5 days
• Earlier is better: each day in delay  risk of death by 20%
• So if influenza is suspected, start treatment empirically

while awaiting test results

Lee and Ison, Clin Infect Dis 2012, 55:1205. Viasus et al, Chest 2011, 140:1025. Muthuri et al, J Infect Dis 2013, 207:553.

10/26/2015 30

Timing of Rx: Better Late than Never

Louie et al, Clin Infect Dis 2012, 55:1198.

Treatment  mortality, even up to 5 days after symptom onset % patients who survived

Rx No Rx Days after symptom onset 1 2 3 4 5

Treatment: High Dose Oseltamivir?

• Is there a benefit of high dose (150mg PO bid)?
• 2 RCTs in 2013 of high vs regular dose oseltamivir x 5d:
• Hospitalized kids or adults, immunocompetent, non‐ICU
• Results: No difference in viral clearance, mortality, duration of

fever, use of O2, ICU admission or intubation, LOS

• High dose oseltamivir was well tolerated
• Conclusion: there is no benefit in hospitalized patients who are

immunocompetent, non‐ICU patients

• What about critically ill or immunocompromised? 

Controversial, some experts still recommend

South East Asia ID Clinical Research Network, BMJ 2013, 346:f3039. Lee et al, Clin Infect Dis 2013, 57:1511. WHO Guidelines for Pharmacological Management of Pandemic Influenza A(H1N1) 2009 and other Influenza Viruses, 2010.

10/26/2015 31

Duration of Therapy

• 5 days in uncomplicated cases
• Consider 10 days in critically ill and

immunocompromised because of longer shedding

• Can consider prolonging the treatment duration

beyond this depending on clinical response and follow‐up testing (although no data for this)

Peramivir (IV)

• FDA approved 12/2014 for adults with uncomplicated

influenza and symptoms <48hrs

• When to use?
• Any concerns for GI absorption of oseltamivir (note: limited

data shows that oseltamivir is well absorbed in obese and critically ill patients icluding those on CRRT and ECMO)

• Patients not responding to oseltamivir? Critically ill patients?
• How to dose?
• FDA approved for a single dose in uncomplicated influenza
• Under the EUA in 2009: was given as a daily dose for 5‐10 days
• UCSF guidelines: 5 days

Whitley et al, Antivir Ther 2014, Oct 15 Epub. Kohno et al, Antimicrob Agents Chemother 2010, 54:4568. de Jong et al, Clin Infect Dis 2014, 59:e172.

10/26/2015 32

Case #6 Continued

After 10 days his influenza PCR is still positive. You decide to treat him for an additional 7 days since he is critically ill. However, he remains critically ill and his PCR continues to be positive.

What is Your Next Step?

• 1. Change to IV oseltamivir
• 2. Start vancomycin and cefepime
• 3. Change to inhaled zanamavir
• 4. Send to the DPH for resistance testing

10/26/2015 33

What If My Patient Doesn’t Get Better?

• Consider oseltamivir resistance
• Especially critically ill or immunocompromised pts who

may shed for weeks

• Send to DPH or CDC
• Rare (<2% of isolates over last 2 years)
• If concerned for resistance  IV zanamivir available via

urgent EIND approval from GSK and the FDA

• Consider whether PO absorption is adequate  if

not, use IV peramivir

Influenza Treatment: Take‐Home Points

• Who to treat?
• All inpatients irrespective of duration of symptoms
• Which drug?
• Oseltamivir (high dose if critically ill, immunocompromised?)
• Zanamivir (only if no COPD/asthma and not intubated)
• Peramivir if need an IV option
• How long?
• 5 days
• Consider 10 d if critically ill, immunocompromised?
• Peramivir: 1 day or 5 days?

10/26/2015 34

Rapid‐Fire Respiratory Viruses

• RSV
• Parainfluenza
• Human metapneumonvirus
• Adenovirus

RSV in Adults

• Epidemiology
• Winter seasonality
• Affects up to 10% of adults/year
• Common cause of CAP
• Clinical:
• Wheezing and dyspnea more common than flu
• Bacterial co‐infection in 12%
• Mortality rate 10% in elderly, >50% in HSCT patients
• CXR findings:
• Normal in 50%
• Unilateral 82%, Consolidation 24%, GGO 20%
• Treatment only in ICH: ribavirin + immunomodulator (IVIG)

Cesario, Clin Infect Dis 2012, 55:107. Lee et al, Clin Infect Dis 2013, 57:1069. Lee et al, Clin Infect Dis 2013, 57:1069. Cesario, Clin Infect Dis 2012, 55:107. Lee et al, Clin Infect Dis 2013, 57:1069.

10/26/2015 35

Parainfluenza

• PIV‐3 is most common type in adults

(PIV‐1 and PIV‐2 cause croup in kids)

• Seasonality is spring‐summer
• Clinical:
• Fever, cough, SOB, wheeze
• Causes URI, bronchiolitis, bronchitis, PNA
• Can be severe in immunocompromised
• No treatment clearly effective (ribavirin, DAS‐181)

Marx et al, Clin Infect Dis 1999, 29:134.

Human Metapneumovirus

• Epidemiology:
• ~4% of CAP
• Seasonality: winter‐spring
• Clinical:
• 40‐70% of infections are asymptomatic
• URI symptoms, cough, wheeze
• Usually afebrile
• CXR infiltrate in 27%
• Can be severe, especially in high risk populations
• Treatment: case reports of using ribavirin + IVIG (like

RSV) in transplant patients

Walsh et al, Arch Intern Med 2008, 168:2489.

10/26/2015 36

Adenovirus

• Can cause severe PNA in ICH host,

rarely in immunocompetent

• The classical features of adenoviral

infection (pharyngitis, conjunctivitis, rash, diarrhea) may be absent

• Diagnosis:
• Some respiratory viral panel PCR assays

are only ~60% sensitive for adenovirus

• If high suspicion, also send the serum PCR

(has  sensitivity)

• Treatment: can consider cidofovir

Louie et al, Clin Infect Dis 2008, 46:421. Clark et al, J Med Case Rep 2011, 5:259. Pabbaraju et al, J Clin Microbiol 2008, 46:3056.

Thank You!

• Questions: jennifer.babik@ucsf.edu