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Viral pathogen presence changes during course of acute sinusitis symptoms
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Upper respiratory infections, or URIs, are more common among children who develop acute sinusitis, according to research published in Clinical Infectious Diseases. Although respiratory syncytial virus was the most common cause of URI among children with sinusitis, 30% of patients with the condition had a new viral pathogen present in samples collected on the 10th day of symptoms, researchers said.
The findings suggest that some children thought to have sinusitis are instead experiencing sequential viral infections, according to Gregory P. DeMuri, MD, professor of pediatric infectious diseases at the University of Wisconsin School of Medicine and Public Health, and colleagues.
The researchers wrote that viral upper respiratory infections may cause inflammation of mucosal membranes in the nose and nasopharynx. This can cause the sinus ostia to become obstructed and allow bacteria to grow in the nasopharynx and cause complications like acute sinusitis and acute otitis media, according to the researchers.
Children aged between 4 and 7 years were enrolled in a longitudinal study for 1 year. Nasal washes were collected upon enrollment and at four visits in which the children were asymptomatic. Additional washes were collected on day 3 or 4 of acute respiratory infection. If acute sinusitis was diagnosed, the researchers collected another wash on day 10. A “recovery sample” was collected on day 15 from children with uncomplicated URI whose symptoms had resolved.
More than 500 URIs were examined during the study period. According to the researchers, 37 illnesses in 31 patients met criteria for acute sinusitis. On day 3, viruses were detected in 81% of uncomplicated URIs and 76% of acute sinusitis cases.
Children were more likely to develop acute sinusitis when their URI was caused by RSV compared with children who had uncomplicated URIs (10.8% vs. 3.4%; P = .05). When DeMuri and colleagues compared day-3 samples with day-10 samples, they observed that new viruses were detected in 22% of children with persistent symptoms and 38% with worsening symptoms — or 29% of all acute sinusitis cases.
The researchers also observed that children who developed sinusitis experienced more URIs annually, with a median of one URI for those with uncomplicated URIs and three URIs for those with sinusitis.
“Overall, these data support the supposition that patients diagnosed with sinusitis using current guidelines who have a new virus detected on the 10th day of illness actually have sequential viral infections,” DeMuri and colleagues wrote. “An alternative supposition is that subjects diagnosed with sinusitis on day 10 have both a new viral infection and bacterial sinusitis. Further studies that assess response to antimicrobial [treatment] are necessary to fully explore these hypotheses.” – by Katherine Bortz
Disclosures: DeMuri reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Deborah Lehman, MD
The diagnosis of sinusitis can be challenging, and clinicians must differentiate a prolonged viral illness with one complicated by bacterial superinfection. Current guidelines recommend against imaging in the diagnostic work up. Physicians should rely on clinical symptoms, including persistent illness (nasal discharge, daytime cough) for more than 10 days, a worsening course of an upper respiratory tract infection following initial improvement, or severe onset of fever and associated symptoms, such purulent nasal discharge.
This careful longitudinal study demonstrates that in up to 30% of patients meeting criteria for sinusitis, a new virus could be identified, bringing into question the ability of clinicians to reliably differentiate bacterial superinfection of a preceding viral infection from a new viral infection. Better diagnostic methods that will identify which children should be treated with antibiotics for persistent or new symptoms following an upper respiratory infection are needed to reduce unnecessary antibiotic administration.
Reference:
Wald ER, et al. Pediatrics. 2013;doi:10.1542/peds.2013-1071.
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