16 Infectious Diseases P EDIATRIC N EWS • March 2008 ID CONSULT Adenovirus Serotype 14: One of Nature’s Pathogen Cycles cute respiratory disease associated quent disease in young children than in the some of the variation in disease severity ting viral cultures more than 5 days into with emerging adenovirus serotype elderly, considering the relative ages of with other viruses as well. We’re just be- the fever may not give you time to make A14 that caused nine deaths last fall Ad14 patients. Among 12 cases with avail- ginning to learn about these mechanisms the diagnosis before you will need to em- in the United States is a development able medical information in Oregon, 11 within the innate immune system. pirically use IVIG. worth noting, but there seems little reason (92%) of non–type-14 adenovirus patients In the meantime, we might want to con- New multiplex polymerase chain reac- to fear this strain will lead to larger ongo- were younger than 5 years, compared with sider obtaining viral cultures—commer- tion (PCR) technology should improve ing outbreaks of “killer colds.” only 5 (17%) out of 30 cases of Ad14. cially available testing systems do include on that situation in the near future. Al- In fact, it is probably part There was, however, one adenovirus—in hospitalized pneumonia ready in use at some teaching institutions, of a natural life cycle that death in a 1-month-old in the patients who do not have positive RSV or multiplex PCR improves the diagnostic ca- has been going on for mil- Ad14 group. influenza rapid tests and who do not im- pacity of traditional PCR by amplifying lennia. We’re only learning But Ad14 is not new. It was prove quickly despite appropriate support- target sequences of multiple viruses all at of these mutations in recent initially described in 1955, ive and perhaps empiric antibiotic therapy. once. The technology allows you to order years because of active sur- and was associated with epi- Even though we don’t have a common- a panel of 17-20 different viral tests in one veillance that the Centers demic of acute respiratory ly used effective antiviral for adenovirus, batch and get the results back in a day (J. for Disease Control and disease in military recruits in such as oseltamivir for influenza, it can be Clin. Microbiol. 2007;45:2965-70), at a cost Prevention now routinely Europe in 1969. According to important to be aware of cases of severe of not much more than the $150-$200 for conducts at sentinel sites the CDC, in 2001-2002 it was adenovirus occurring outside of the sur- the current viral panel of just 6 or 7. around the country. When reported to be associated veillance network. While Ad14 is a recent Another new technology on the hori- the system detects some- with approximately 8% of all culprit, other serotypes also have been im- zon—flocked nasal swabs—will make it BY CHRISTOPHER thing noteworthy, the find- J. HARRISON, M.D. respiratory adenoviral infec- plicated in sporadic outbreaks. Also, if you easier to obtain the sample from the child. ings are published in the tions in the pediatric ward of have a firm viral diagnosis, you don’t need Currently approved for use in adults, the Morbidity and Mortality a Taiwan Hospital. to keep escalating broad-spectrum antibi- swabs are made with perpendicular nylon Weekly Report (MMWR). Media are However, because Ad14 hasn’t been cir- otics. Adenovirus can initially mimic the fibers that allow you to collect epithelial mining the MMWR for stories, we’re culating in a while—it’s just one of at least high fever, leukocytosis, and ill-appearing cells and surrounding pathogens with a seeing frequent infectious disease stories 42 different adenovirus strains—the cur- presentation of bacterial pneumonia, par- few simple twirls in the nares, a technique with alarmist headlines. We should be rent population isn’t likely to be immune. ticularly in young children. The x-ray find- far more comfortable for the patient than prepared to explain them to worried par- While most healthy individuals are still ings usually are bilateral and patchy initial- a nasal wash. Data from the company’s ab- ents of patients. able to mount an immune response to it, ly, but the infiltrates can become dense and stracts suggest that the sample you get As we know, adenovirus typically isn’t a certain susceptible people will become appear more “bacterial” as time goes on. from the swab is equivalent to that from life-threatening problem. In 99% of cases more ill, including the very old, the very Another reason to culture for aden- the nasal wash (information available at it’s a self-limited infection that causes con- young, and those with compromised im- ovirus is its potential to mimic Kawasaki www.copanusa.com). junctivitis, rhinorrhea, exudative pharyn- mune systems; perhaps some healthy peo- disease, with the nonpurulent conjunc- These new modalities together should gitis, and/or fever for 3-8 days. ple will have a genetic predisposition that tivitis, red throat, mucositis, high fever, and make viral testing as simple as taking a Adenovirus serotype 14 (Ad14) does ap- makes them more vulnerable. swollen lymph nodes. If you can confirm throat culture for the group A strepto- pear to be a bit different, though: In May Indeed, a single nucleotide polymor- that the child actually has adenovirus dur- coccus bacterium, and allow us to obtain 2006, a 12-day-old infant in New York died phism (SNP)—one change in the DNA of ing the Kawasaki work-up, you can save timely information that is more pertinent of respiratory illness caused by “Ad14.” a key gene—can have a dramatic effect on thousands of dollars that would otherwise while the child is still sick. But at the same From March to June 2007, a total of 140 ad- how a person responds to environmental be spent on intravenous immune globulin time we need to remind our patients—and ditional cases of confirmed Ad14 respira- or infectious triggers. Consider as an ex- (IVIG) therapy. Of course, to be really use- ourselves—that in the vast majority of tory illness were identified in clusters of pa- ample the case of a disease that we are ful, you’ll need to get the viral cultures cases we’re not talking about a “killer” dis- tients in Oregon, Washington, and Texas. more familiar with than Ad14, respirato- early, because current culture tech- ease, even with adenovirus. ■ Of those, 38% were hospitalized and 5% ry syncytial virus (RSV) in children. Hos- niques—shell vial or standard—require died (MMWR 2007;56:1181-4). Deaths pitalization and more severe symptoms anywhere from 48 hours to 7 days for re- DR. HARRISON is professor of pediatrics and were due to progressive pneumonias, not have been demonstrated with one SNP sults to develop. Because the window of pediatric infectious diseases at Children’s colds. (Pediatr. Infect. Dis. J. 2007;26:1094-8), and effective use of IVIG in Kawasaki disease Mercy Hospitals and Clinics, Kansas City, It’s possible that Ad14 produces less fre- it’s likely that similar mechanisms explain is within 10 days of the onset of fever, get- Mo. Write to him at [email protected]. Don’t Rule Out Retropharyngeal Abscess in Sore Throats BY HEIDI SPLETE because treatment delays could The abscess may follow an up- voice. The classic symptoms of agement, and hydration before Senior Writer lead to life-threatening complica- per respiratory infection, group A neck stiffness and bulging of the admitting the child to the hospi- tions such as a blocked airway, β-hemolytic streptococcal pharyn- posterior pharyngeal wall are tal. Consult an ear, nose, and onsider a retropharyngeal jugular vein thrombosis, or medi- gitis (GABHS), or even trauma. present in fewer than 50% of pa- throat specialist when the diag- Cabscess when faced with a astinitis, Dr. Figueira explained in The predominant bacterial tients, Dr. Figueira said. nosis is confirmed or if the child drooling child who has a severe a presentation at a conference on species are Streptococcus pyogenes, On physical examination, the has an obstructed airway. The sore throat, according to Dr. infectious diseases held child can present with treatment plan for a retropha- Marisol Figueira of Boston Uni- in Cambridge, Mass. Prompt diagnosis is important anterolateral neck ryngeal abscess includes incising versity. The retropharyngeal swelling, hyperexten- and draining the abscess, and “Retropharyngeal abscess is a space extends from the because treatment delays could lead sion of the neck, or an treating the child with parenter- commonly seen pathology sec- base of the skull to the to life-threatening complications such enlarged cervical al antibiotics such as clindamycin ondary to acute infection of the level of the T1 or T2 ver- as a blocked airway, jugular vein lymph node, she ex- or a combination of ampicillin throat,” Dr. Figueira said in an in- tebra, and includes the plained at the meeting, and sulbactam. terview. “It is a result of suppu- space behind the mus- thrombosis, or mediastinitis. which was sponsored “Prompt diagnosis and treat- ration of the retropharyngeal cles of the pharynx but by the university. ment of pharyngitis or upper res- lymph nodes, secondary to in- in front of the prevertebral fascia. Staphylococcus aureus, and respira- Imaging is needed to confirm a piratory infections will generally fection in the adenoid, nasophar- An infection in the retropha- tory anaerobes (including Fu- diagnosis of a retropharyngeal ab- prevent retropharyngeal ab- ynx, posterior pharyngeal wall, ryngeal space is most common in sobacteria, Prevotella, and Veillonel- scess.