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Otitis and Respiratory Distress Episodes Following a Respiratory Syncytial Virus Infection D

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Otitis and Respiratory Distress Episodes Following a Respiratory Syncytial Virus Infection D View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector ORIGINAL ARTICLE Otitis and respiratory distress episodes following a respiratory syncytial virus infection D. A. Kafetzis, H. Astra, M. Tsolia, G. Liapi, J. Mathioudakis and K. Kallergi Second Department of Pediatrics, University of Athens, P. & A. Kyriakou Children's Hospital, Athens, Greece Objective To document, over two consecutive respiratory syncytial virus (RSV) seasons, the occurrence of acute otitis media (AOM) and recurrence of respiratory distress in children <2 years of age hospitalized for respiratory distress. Methods Patients were examined during hospitalization and at 6 weeks and 6 months after discharge. RSV testing was performed on all patients, and hospitalized patients were evaluated daily for the occurrence of AOM. Results In total, 347 children were enrolled; 54.8% were RSV positive, and 45.2% were RSV negative. Children were most frequently diagnosed as having bronchiolitis (71.9%) or asthmatic bronchitis (17.9%); other diagnoses included pneumonia, laryngitis, and rhinitis. During hospitalization, AOM was diagnosed in 16.8% of RSV-positive versus 8.3% of RSV-negative children (P < 0.05). Six weeks after discharge, AOM was reported in 10.4% of RSV-positive as compared with 5.8% of RSV-negative patients. Six months later, AOM was reported in 2.9% of the RSV-positive and 7.6% of the RSV-negative patients. A second episode of acute respiratory distress, which either required (9) or did not require (35) hospitalization, occurred in 18.4% of the total population, with similar proportions of RSV-positive and RSV-negative children (17% versus 18.6%). Conclusion We conclude that RSV appears to be an important contributing factor for the occurrence of AOM in young children hospitalized with respiratory distress. The occurrence of a second episode of acute respiratory distress did not appear to correlate with the previous RSV infection, but longer-term follow-up is required. Keywords RSV, otitis media, respiratory distress, bronchiolitis Accepted 25 November 2002 Clin Microbiol Infect 2003; 9: 1006±1010 be connected more commonly with RSV infections INTRODUCTION than with other viral infections [2±8]. Respiratory syncytial virus (RSV) is one of the To our knowledge, the short-term sequelae of major causes of lower as well as upper respiratory hospitalization for acute respiratory distress tract infection in children all over the world. (including RSV infection) have not been exten- Bronchiolitis is the primary lower respiratory tract sively studied [9±13]. We therefore prospectively infection caused by RSV, and is the main reason for examined the occurrence of AOM during hospi- hospitalization during infancy [1]. Acute otitis talization, and the reoccurrence of AOM and media (AOM) is also a common infection affecting respiratory distress after 6 weeks and 6 months mainly infants and young children. In retrospec- following hospitalization for respiratory distress tive studies, it has been observed that AOM might over two consecutive RSV seasons. Corresponding author and reprint requests: D. A. Kafetzis, METHODS Second Department of Pediatrics, University of Athens, P. & Eligible participants were children between A. Kyriakou Children's Hospital, Athens 11527, Greece Tel/Fax: 30 1 6743381 2 weeks and 2 years of age who were admitted E-mail: [email protected] to the P. & A. Kyriakou children's hospital due to ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases Kafetzis et al Otitis, respiratory distress episodes and RSV infection 1007 respiratory distress during the RSV season and incubated in a humid chamber for 30 min at 35± who were not under RSV prophylaxis. The parents 37 8C. After incubation, the slide was carefully of the patients were informed, and written consent washed in PBS, air-dried, and examined micro- was obtained from each of them. The study was scopically (¯uorescence microscope) under Â400 approved by the Ethical Committee of our hospi- magni®cation. A specimen showing one or more tal. Study months included 1 January 1999 to 30 intact columnar epithelial cells with the character- June 1999, and 1 December 1999 to 30 June 2000. istic apple-green cytoplasmic ¯uorescence was During the months of July to November 1999, no considered to be positive for RSV. The typical patients were enrolled because of the low inci- staining morphology included small to large cyto- dence of RSV in Greece during this season. All plasmic inclusions or ®ne particulate ¯uorescence. patients had symptoms and signs of respiratory Specimens with at least 100 columnar epithelial distress, such as tachypnea, intercostal or subcos- cells per well and not exhibiting any speci®c posi- tal retractions, and low O2 saturation (<95%). tive ¯uorescence were considered to be negative Respiratory diagnoses included bronchiolitis, for RSV. Specimens with fewer than 100 cells/well asthmatic bronchitis, laryngitis, rhinitis and pneu- were considered to be inadequate, and the proce- monia. Bronchiolitis was de®ned as an acute lower dure was repeated to exclude the possibility of respiratory tract illness characterized by cough, poor ®xing. When the specimen did not have a signs of respiratory distress, a prolonged expira- satisfactory number of cells, due to poor ®xing, the tory phase, and the presence of wheezing and/or procedure was repeated. If the specimen contin- `crackles'. Only children hospitalized with a ®rst ued to have an unsatisfactory number of cells, it episode of wheezing were classi®ed as having was excluded in order to avoid a false-negative bronchiolitis. If one or more episodes of wheezing result. had occurred previously, the diagnosis of asth- The immuno¯uorescence techniques for detect- matic bronchitis was used. Laryngitis was de®ned ing RSV antigen are usually very sensitive and as an upper respiratory tract infection with char- speci®c (sensitivity as high as 97% and speci®city acteristic `croupy' cough and signs of respiratory greater than 90%) in comparison to culture. The distress. Rhinitis was characterized by nasal dis- actual sensitivity and speci®city are probably charge and nasal obstruction, which in young higher than reported, because culture itself is infants was noted with signs of respiratory distress not 100% sensitive [14,15]. but without wheezing or `crackles'. Pneumonia Upon admission, all patients had a complete was de®ned by the presence of consolidations clinical examination; examinations were repeated on chest X-ray in patients with localized `crackles' and recorded daily during hospitalization. AOM in the affected area. was de®ned when bulging and/or opacity of the Nasopharyngeal washings were obtained from tympanic membrane was observed and accompa- each patient within the ®rst 24 h of hospitalization, nied by one or more signs of acute infection, such and were tested for RSV antigen with a direct as: ear pain, including unaccustomed tugging or ¯uorescence assay (DFA) (Mono¯uo Screen RSV, rubbing of the ear, and marked redness of the Sano® Diagnostics, Pasteur, Marnes la Coguette, tympanic membrane. AOM was also diagnosed France). The DFA procedure followed the recom- when purulent otorrhea was present. The diagno- mendations of the supplier. Each specimen was sis of AOM was made by an ear, nose and throat resuspended in 2±3 mL of phosphate-buffered (ENT) specialist of our hospital who was blinded saline (PBS) and vortexed for about 10 s; this to the diagnosis of RSV. Following hospital dis- was followed by centrifugation at 1500 rev/min charge, all parents who lived in Athens were asked for 5 min, to pellet cellular material. The cell pellet to contact study investigators if any signs or symp- was washed twice with PBS, or until the specimen toms of AOM or respiratory disease occurred, and was virtually free of mucus. The cells were resus- they were referred to either a blinded ENT spe- pended in 0.3 mL of PBS, and 25 mL of the suspen- cialist of our hospital or to us, respectively. For sion was applied to a 13-mm-diameter well of a patients who lived in other cities, parents were multiwell microscopic slide. The slide was air- asked to visit an ENT specialist or a pediatrician in dried, ®xed with cold acetone for 10 min, rinsed their own city, with whom we made contact. in distilled water, and air-dried before staining. Approximately 6±8 weeks following hospital dis- The slide was overlaid with the DFA stain, and charge, the parents of each child were contacted by ß 2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 9, 1006±1010 1008 Clinical Microbiology and Infection, Volume 9 Number 10, October 2003 telephone. This time period was considered suf®- Table 1 Characteristics of study participants cient for short-term follow-up, because an episode Characteristics RSV RSVÀ P-value of AOM during hospitalization should be resolved within that period of time [16]. Parents were ques- Age (months) <39150<0.005 tioned about the health status of the child, whether 3±6 48 27 <0.005 an episode of AOM or respiratory disease had 6±12 38 43 0.12 occurred within that period, and if they had visited 12±24 13 37 <0.005 an ENT specialist or pediatrician but for some Sex Male 126 98 reason had not contacted us. The speciality of the Female 64 59 physician who made the diagnosis (family physi- Days of hospitalization 6.57 4.53 cian, pediatrician, or ENT specialist) was recorded, Smoking of parents 62.7% 77.6% 0.029 and the physician was contacted by one of the Smoking during pregnancy 19.8% 29.4% 0.051 investigators in order to record any episode. A Breast-fed 57% 45.7% 0.036 Center of attendance 2.1% 6.3% 0.042 second phone call was made 6 months after hos- Family history of atopy 31.6% 40.6% 0.080 pital discharge; the same questions were asked, Older siblings 58.7% 65.3% 0.183 and the same procedure was followed.
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