Haemophilus Influenzae Infections Clinical Presentation

  • Author: Vidya R Devarajan, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 10, 2012
 

History

  • Meningitis
    • Meningitis is the most serious manifestation of H influenzae type b (Hib) infection. Symptoms of antecedent URTI are common. Altered mental status and fever are the most common presenting features. Headache and photophobia are usually present in older children.
    • Symptoms related to other infectious foci (eg, cellulitis, arthritis, pneumonia) are encountered in 10-20% of children. Infants have nonspecific symptoms, including irritability, fever, lethargy, poor feeding, and vomiting.
    • H influenzae accounts for 5-10% cases of adult meningitis, and patients can present with at least one of the classic triad of fever, neck stiffness, and altered mental status.
  • Cellulitis: The buccal and periorbital regions are most commonly involved with associated fever. Orbital cellulitis is uncommon and tends to be a complication of ethmoid or sphenoid sinusitis.
  • Epiglottitis: Patients have histories of fever, sore throat, dysphagia, drooling, and difficulty breathing.
  • Pneumonia: Hib pneumonia is clinically indistinguishable from other bacterial pneumonias except for its insidious onset and a patient history of fever, cough, and purulent sputum production.
  • Pericarditis: Patients with Hib pericarditis present with a history of fever, respiratory distress, and tachycardia.
  • Septic arthritis: Patients note joint pain, swelling, and decreased mobility.
  • Occult bacteremia: Fever, anorexia, and lethargy occur in persons with occult bacteremia.
  • Underlying medical conditions: Pulmonary disease, HIV infection (and other immunodeficiency states), alcoholism, pregnancy, and malignancy may predominate in adults with invasive Hib disease.
  • Neonatal infections
    • Neonates with H influenzae disease present within 24 hours of birth; these infections are caused by NTHi strains, which colonize the maternal genital tract.
    • Premature birth, premature rupture of membranes, low birth weight, and maternal chorioamnionitis are associated with H influenzae disease.
    • Manifestations may be nonspecific and may include those of bacteremia, sepsis, meningitis, pneumonia, respiratory distress, scalp abscess, conjunctivitis, and vesicular eruption.
    • NTHi is a major cause of pneumonia in infants in developing countries.
  • Nonencapsulated H influenzae infections
    • Nonencapsulated H influenzae commonly causes various mucosal infections, including otitis media and conjunctivitis.
    • S pneumoniae and nonencapsulated H influenzae are the most common causes of otitis media, which manifests in infants as fever and irritability and in older patients as ear pain. Frequently, a history of URTI exists.
    • NTHi is a major cause of conjunctivitis in older children and can cause outbreaks, especially in daycare centers. After S pneumoniae, NTHi is the most common cause of community-acquired bacterial pneumonia in adults. It is common in patients with COPD and HIV disease and exacerbates COPD, symptoms of which include low-grade fever, increased cough and sputum production, and dyspnea. NTHi invasive disease is frequently associated with underlying medical conditions, including prematurity, advanced age, alcoholism, malignancy, CF, asthma, cerebrospinal fluid (CSF) leak, CNS shunts, congenital heart disease, and immunoglobulin deficiency.
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Physical

  • Meningitis
    • Clinical manifestations of Hib meningitis are indistinguishable from other causes of bacterial meningitis.
    • The usual presentation consists of a few days of mild illness followed by ominous deterioration.
    • Altered mental status and fever are the most common findings.
    • Seizures and coma develop as the disease progresses.
    • Children may have few specific signs. Nuchal rigidity is often absent in children younger than 18 months. In infants, the disease course may be fulminant, with death occurring within a few hours.
    • Consider the possibility of subdural effusion, a common complication of Hib meningitis, in a patient who has been treated for 3 days with appropriate antibiotics and has experienced a tense anterior fontanelle, seizures (especially if focal), hemiparesis, or altered CNS function.
  • Cellulitis
    • The clinical features are fever and a raised, indurated, tender area with indistinct margins mostly on the head and neck, particularly the buccal and preseptal areas. This is often caused by contiguous sinus disease. The indurated area may progress to a violaceous hue, although this is not specific to Hib.
    • Orbital cellulitis may also occur and is distinguished from preorbital cellulitis based on the presence of proptosis, chemosis, impaired vision, limitation of extraocular movements, and pain with eye movement. A secondary focus of infection, including meningitis, is evident in 10-15% of patients with orbital cellulitis.
  • Epiglottitis: Clinical manifestations in children include a toxic anxious appearance, progressive respiratory difficulty, and the inability to swallow secretions while sitting in the tripod position (ie, sitting with arms back, trunk leaning forward, neck hyperextended and chin forward in an attempt to open the airway fully).
  • Pneumonia: Hib pneumonia is clinically indistinguishable from other bacterial pneumonias.
  • Pericarditis: The individual is acutely ill with fever and respiratory distress.
  • Septic arthritis
    • Hib septic arthritis affects single large joints (eg, knee, ankle, hip, elbow).
    • Symptoms, usually preceded by a URTI, include decreased range of motion, erythema, and warmth and swelling in affected joints, in addition to fever.
    • In adults, joint involvement can be monoarticular or polyarticular.
    • Extra-articular sites of infection, including those associated with meningitis, pneumonia, cellulitis, and sinusitis, may also be evident.
  • Occult bacteremia: Occult bacteremia is characterized by fever (temperature >39°C) with no obvious focus of infection. About 30-50% of patients have focal infections.
  • Nonencapsulated H influenzae infections can manifest in various mucosal infections (eg, otitis media, conjunctivitis, sinusitis, bronchitis). An otitis media diagnosis is confirmed with pneumatic otoscopy. Conjunctivitis is usually bilateral and characterized by conjunctival hyperemia and purulent eye discharge.
  • NTHi strains can cause postpartum sepsis with endometritis, tuboovarian abscess, and chronic salpingitis.
  • Signs of invasive disease in neonates include sepsis, pneumonia, conjunctivitis, respiratory distress syndrome, scalp abscess, cellulitis, meningitis, congenital vesicular eruption, mastoiditis, and septic arthritis.
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Causes

  • Bacteremia precedes Hib meningitis and other invasive Hib diseases.
    • Direct extension of infection from the sinuses or ears is rare.
    • The magnitude and duration of bacteremia are the primary determinants of CNS invasion, which occurs via the choroid plexus.
    • The magnitude of the CSF bacterial density correlates with the severity of the disease.
    • Morbidity and mortality associated with meningitis result from inflammation, edema, and increased CSF pressure.
    • Brain parenchymal invasion is rare.
  • In epiglottitis, Hib invades the epiglottis and supraglottic tissues, causing cellulitis and swelling that causes the epiglottis to curl posteriorly and inferiorly over the airway, thus obstructing airflow during inspiration but allowing normal expiration. An acute airway obstruction follows.
  • Invasive H influenzae disease in neonates is rare and is caused most often by NTHi strains.
    • This condition is associated with premature birth, premature rupture of membranes, low birth weight, and maternal chorioamnionitis.
    • Transmission occurs through the maternal genital tract.
    • NTHi biotype 4 can colonize the genital tract and is a major cause of invasive disease.
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Contributor Information and Disclosures
Author

Vidya R Devarajan, MD 

Disclosure: Nothing to disclose.

Specialty Editor Board

Wesley W Emmons, MD, FACP  Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE

Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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