All that coughs and sneezes is not the flu and RSV

February can be a busy time for the infectious disease physician, especially in pediatrics. Many patients I see present with a history of the typical symptoms of an influenza-like illness with complications of disease or underlying illness that lands them in the hospital.

These days, it’s almost a guarantee that if a child is admitted with fever, they will likely get tested for influenza and respiratory syncytial virus when passing through the ED. Thus, it was not surprising when my service was consulted on a 2-year-old former 34-week premature toddler who presented with symptoms of respiratory tract infection with distress, and he had already undergone rapid influenza and RSV studies, which were negative.

This was followed by specific PCRs for RSV and influenza, both of which were likewise negative. The private pediatrician caring for this patient was concerned about the lack of clinical improvement on empiric coverage for community-acquired pneumonia (CAP) and wanted the opinion of the Infectious Disease service on this patient’s diagnosis of CAP and course.

I thought, “What an excellent learning opportunity for my medical student to review the differential of CAP in the pediatric patient!”

So, I had my intrepid medical student hurry down to see the patient.

In her discussion about the viral causes of the patient’s presenting symptoms, she stopped short after listing influenza and RSV. I was surprised to learn that she had never heard of human metapneumovirus (HMPV), but when I thought about it, I realized that HMPV was not something I had been taught during medical school either. Medical curricula are slow to follow the current state of medical knowledge, and HMPV is a new virus on the block. It was first described formally in 2001. The timing of this discussion was perfect, as a recent report from the New Vaccine Surveillance Network on HMPV was just published in the Feb. 14 issue of The New England Journal of Medicine.

In this study, the group led by senior researcher John V. Williams, MD, of Vanderbilt University School of Medicine in Nashville sought to describe the inpatient and outpatient HPMV disease burden for children presenting with acute respiratory illness. They performed a prospective survey of respiratory illness or fever in inpatient and outpatient children aged younger than 6 years in three US counties from 2003 to 2009. They found that HMPV was present in 6% of hospitalized children; 7% of the ambulatory care visits during that time period; and with a baseline prevalence of 1% in children with no symptoms of illness. They also found that children with HMPV were more likely to require supplemental oxygen and have longer ICU stays. Click here to read the full story.

Following our discussion about HMPV and these recent findings on disease prevalence, we agreed that we would send this child’s nasal wash for HPMV PCR, and indeed this was the answer for this patient. The child improved with a few more days of supportive care off antibiotics and was discharged to home in good health.

This little boy’s case served not only an excellent learning opportunity for my medical student, but also served as a reminder to the more senior providers to always consider HMPV in differential for young children presenting with an acute respiratory illness.