eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Pneumonia, Viral: Follow-up

Author: Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Contributor Information and Disclosures

Updated: Apr 28, 2009

Follow-up

Deterrence/Prevention

  • Influenza
    • Annual fall vaccination of high-risk populations and health care workers is the most effective measure for decreasing morbidity and mortality from influenza.27 Antibodies against the hemagglutinin and, to a lesser degree, neuraminidase antigens are the major determinants of host immunity. Each year's influenza vaccine contains the 3 virus strains (usually 2 type A strains and 1 type B strain) considered most likely to cause outbreaks based on epidemiologic surveillance.
    • The effectiveness of the vaccine depends on the age and general health status of the recipient and the antigenic similarity to the virus causing outbreaks that year. When the vaccine matches the prevalent influenza virus strain, the efficacy of the vaccine in healthy adults is reported to be in the range of 70-90%. Contrary to popular belief, the flu vaccine cannot cause the flu. Also, the potential association between flu vaccine and Guillain-Barré syndrome is highly overemphasized. Finally, patients with severe allergy to eggs should not be offered the vaccine.
    • Chemoprophylaxis with amantadine or rimantadine should be considered when outbreaks occur in nursing homes. Everyone in the institution, including the unvaccinated staff and other coworkers, should be treated for at least 2 weeks during the outbreak.
    • Zanamivir and oseltamivir also have been shown to be effective in the prevention of influenza if taken within 42 hours of the onset of symptoms.
    • In view of the high fatality of avian influenza, a combination of contact, droplet, and airborne precautions are recommended as long as resources allow, despite the fact that the relative importance of these 3 modes in nosocomial transmission of avian influenza is still unknown.
  • Respiratory syncytial virus
    • RSV immunoglobulin is a pooled product containing immunoglobulin G antibodies against RSV. When administered intravenously to patients at high risk, fewer episodes of severe pneumonia requiring hospitalization have occurred.
    • An alternative to RSV immunoglobulin is palivizumab (Synagis), which is an intramuscularly administered humanized monoclonal antibody preparation. Prophylaxis with this agent results in a 55% reduction in hospitalization secondary to RSV infection in high-risk pediatric patients.
  • Herpes simplex virus: Chemoprophylaxis of high-risk seropositive patients during induction of immunosuppression for transplantation is recommended. Acyclovir is prescribed at maintenance doses for the first month after transplantation.
  • Varicella-zoster virus
    • A live attenuated varicella vaccine is recommended for patients who did not have varicella infection by age 13 years if their work involves the possibility of exposure to varicella. The vaccine should not be given to pregnant women. Children are now routinely immunized.
    • Intramuscular administration of varicella-zoster immunoglobulin (125 U/10 kg) is indicated for passive immunization VZV-seronegative immunosuppressed hosts (including pregnant women and certain neonates) who have been exposed to VZV.
  • Measles
    • The measles vaccine is a live attenuated virus vaccine and should not be administered to pregnant women or persons who are severely immunocompromised.
    • Postexposure prophylaxis of patients who are immunocompromised with intravenous immunoglobulin is effective if administered within 72 hours of exposure to infectious cases of measles.
  • Adenovirus: An oral vaccine is available against serotypes 5 and 7. This vaccine has been used primarily in military recruit populations and is not currently available.
  • Cytomegalovirus: CMV infection is prevented in transplant patients by attempts to match the CMV seropositivity between the donor and the recipient and by careful administration of CMV-negative transfusions of blood and blood products. Graft recipients who are CMV negative are given prophylactic acyclovir or ganciclovir before and after transplantation. Preemptive therapy based on detection of CMV in bronchoalveolar lavage specimens and CMV antigenemia after transplant has been shown to significantly reduce the incidence of posttransplant CMV pneumonia.

Complications

  • Most viral pneumonias in hosts who are immunocompetent resolve with few sequelae. However, respiratory failure may develop secondary to superimposed bacterial infection.
  • Secondary bacterial infections occur commonly. Common organisms are Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae.
  • A risk of acquiring other hospital-acquired bacterial infections is present.
  • Late sequelae of viral pneumonias include bronchitis and bronchiolitis, especially following infection with RSV and influenza viruses.

Patient Education

For excellent patient education resources, visit eMedicine's Pneumonia Center and Cold and Flu Center. Also, see eMedicine's patient education articles Viral Pneumonia and Flu in Adults.

Miscellaneous

Medicolegal Pitfalls

  • Patients with viral pneumonias, especially persons who are immunocompromised, should be evaluated carefully to exclude bacterial infections. Empiric therapy for bacterial pneumonia usually is warranted while the etiologic evaluation proceeds.
  • Patients who meet criteria for either chemoprophylaxis or immunoprophylaxis should be offered such interventions when appropriate.
  • In influenza, the antiviral drugs should usually be started within 24-48 hours of symptom onset. A later initiation may be warranted for life-threatening pneumonia, but no good data are available to address this issue.
  • Zanamivir may lead to worsening of airway function in patients with asthma or COPD.
  • Inadequate data are available on the use of antiinfluenza drugs in patients who are immunosuppressed and at high risk for influenza-related complications. Use if life-threatening disease is present.
  • Clinical and radiographic features of viral pneumonias often are nonspecific. Newer and faster methods of viral culture and viral antigen detection have improved the capability of definitive diagnosis, but further refinements in diagnostic techniques are needed.
  • Preventative measures should be practiced when applicable. These measures should focus on limiting exposure to active infection, broad use of available vaccines in children and susceptible adults, and use of hyperimmune globulins and chemoprophylaxis in patients at high risk.

Special Concerns

Viral pneumonia in the elderly: Viruses account for a substantial portion of respiratory illnesses, including pneumonia, in the elderly population. Presently, influenza virus A H3N2 and respiratory syncytial virus are the most commonly identified viral pathogens in older adults with viral pneumonia. The relative importance of additional viruses (such as parainfluenza, rhinoviruses, coronaviruses, and human metapneumovirus) will likely increase as diagnostic tests such as reverse-transcription polymerase chain reaction become more widely available.

Patients with high-grade fever, myalgias, and cough during the winter months should be suspected to have influenza. If tests are negative for influenza, respiratory syncytial virus pneumonia should also be suspected during the winter in patients with coryza, wheezing, low-grade fever, and patchy infiltrates on chest x-ray. Because clinical features and periods of activity for many viruses overlap, laboratory confirmation of influenza is recommended for cases involving patients who are seriously ill or institutionalized.

     


    More on Pneumonia, Viral

    Overview: Pneumonia, Viral
    Differential Diagnoses & Workup: Pneumonia, Viral
    Treatment & Medication: Pneumonia, Viral
    Follow-up: Pneumonia, Viral
    Multimedia: Pneumonia, Viral
    References
    Further Reading
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    References

    1. Shields AF, Hackman RC, Fife KH, Corey L, Meyers JD. Adenovirus infections in patients undergoing bone-marrow transplantation. N Engl J Med. Feb 28 1985;312(9):529-33. [Medline].

    2. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. The Hantavirus Study Group. N Engl J Med. Apr 7 1994;330(14):949-55. [Medline].

    3. Levy H, Simpson SQ. Hantavirus pulmonary syndrome. Am J Respir Crit Care Med. Jun 1994;149(6):1710-3. [Medline].

    4. Sims LD, Domenech J, Benigno C, et al. Origin and evolution of highly pathogenic H5N1 avian influenza in Asia. Vet Rec. Aug 6 2005;157(6):159-64. [Medline].

    5. Wong SS, Yuen KY. Avian influenza virus infections in humans. Chest. Jan 2006;129(1):156-68. [Medline].

    6. de Jong MD, Hien TT. Avian influenza A (H5N1). J Clin Virol. Jan 2006;35(1):2-13. [Medline].

    7. US Department of Health and Human Resources. HHS Declares Public Health Emergency for Swine Flu. Available at http://www.hhs.gov/news/press/2009pres/04/20090426a.html. Accessed April 27, 2009.

    8. Centers for Disease Control and Prevention. Swine Influenza (Flu). Available at http://www.cdc.gov/swineflu. Accessed April 27, 2009.

    9. World Health Organization. Swine flu illness in the United States and Mexico – update 2. Available at http://www.who.int/en/. Accessed April 27, 2009.

    10. Centers for Disease Control and Prevention. Guidance for Clinicians and Public Health Professionals. Available at http://www.cdc.gov/swineflu/guidance. Accessed April 27, 2009.

    11. Anderson DJ, Jordan MC. Viral pneumonia in recipients of solid organ transplants. Semin Respir Infect. Mar 1990;5(1):38-49. [Medline].

    12. Harrington RD, Hooton TM, Hackman RC, et al. An outbreak of respiratory syncytial virus in a bone marrow transplant center. J Infect Dis. Jun 1992;165(6):987-93. [Medline].

    13. Meyers JD, Flournoy N, Thomas ED. Nonbacterial pneumonia after allogeneic marrow transplantation: a review of ten years' experience. Rev Infect Dis. Nov-Dec 1982;4(6):1119-32. [Medline].

    14. Falsey AR, Walsh EE. Viral pneumonia in older adults. Clin Infect Dis. Feb 15 2006;42(4):518-24. [Medline].

    15. Falsey AR, McCann RM, Hall WJ, Criddle MM. Evaluation of four methods for the diagnosis of respiratory syncytial virus infection in older adults. J Am Geriatr Soc. Jan 1996;44(1):71-3. [Medline].

    16. Osiowy C. Direct detection of respiratory syncytial virus, parainfluenza virus, and adenovirus in clinical respiratory specimens by a multiplex reverse transcription-PCR assay. J Clin Microbiol. Nov 1998;36(11):3149-54. [Medline].

    17. Hayden FG, Osterhaus AD, Treanor JJ, et al. Efficacy and safety of the neuraminidase inhibitor zanamivir in the treatment of influenzavirus infections. GG167 Influenza Study Group. N Engl J Med. Sep 25 1997;337(13):874-80. [Medline].

    18. Hayden FG, Treanor JJ, Fritz RS, et al. Use of the oral neuraminidase inhibitor oseltamivir in experimental human influenza: randomized controlled trials for prevention and treatment. JAMA. Oct 6 1999;282(13):1240-6. [Medline].

    19. Hayden FG, Atmar RL, Schilling M, et al. Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza. N Engl J Med. Oct 28 1999;341(18):1336-43. [Medline].

    20. Hirji Z, O'Grady S, Bonham J, et al. Utility of zanamivir for chemoprophylaxis of concomitant influenza A and B in a complex continuing-care population. Can Commun Dis Rep. Feb 1 2001;27(3):21-4. [Medline].

    21. Monto AS, Fleming DM, Henry D, et al. Efficacy and safety of the neuraminidase inhibitor zanamivirin the treatment of influenza A and B virus infections. J Infect Dis. Aug 1999;180(2):254-61. [Medline].

    22. Treanor JJ, Hayden FG, Vrooman PS, et al. Efficacy and safety of the oral neuraminidase inhibitor oseltamivir in treating acute influenza: a randomized controlled trial. US Oral Neuraminidase Study Group. JAMA. Feb 23 2000;283(8):1016-24. [Medline].

    23. de Jong MD, Tran TT, Truong HK, et al. Oseltamivir resistance during treatment of influenza A (H5N1) infection. N Engl J Med. Dec 22 2005;353(25):2667-72. [Medline].

    24. American Academy of Pediatrics Committee on Infectious Diseases. Use of ribavirin in the treatment of respiratory syncytial virus infection. Pediatrics. Sep 1993;92(3):501-4. [Medline].

    25. Davidson RN, Lynn W, Savage P, Wansbrough-Jones MH. Chickenpox pneumonia: experience with antiviral treatment. Thorax. Aug 1988;43(8):627-30. [Medline].

    26. Forni AL, Schluger NW, Roberts RB. Severe measles pneumonitis in adults: evaluation of clinical characteristics and therapy with intravenous ribavirin. Clin Infect Dis. Sep 1994;19(3):454-62. [Medline].

    27. Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA. Mar 10 1999;281(10):908-13. [Medline].

    28. Balfour HH Jr. Antiviral drugs. N Engl J Med. Apr 22 1999;340(16):1255-68. [Medline].

    29. Dowell SF, Anderson LJ, Gary HE Jr, et al. Respiratory syncytial virus is an important cause of community-acquired lower respiratory infection among hospitalized adults. J Infect Dis. Sep 1996;174(3):456-62. [Medline].

    30. Feldman S. Varicella-zoster virus pneumonitis. Chest. Jul 1994;106(1 Suppl):22S-27S. [Medline].

    31. Feldman S, Stokes DC. Varicella zoster and herpes simplex virus pneumonias. Semin Respir Infect. Jun 1987;2(2):84-94. [Medline].

    32. Foy HM, Cooney MK, Allan I, Kenny GE. Rates of pneumonia during influenza epidemics in Seattle, 1964 to 1975. JAMA. Jan 19 1979;241(3):253-8. [Medline].

    33. Greenberg SB. Viral pneumonia. Infect Dis Clin North Am. Sep 1991;5(3):603-21. [Medline].

    34. Gremillion DH, Crawford GE. Measles pneumonia in young adults. An analysis of 106 cases. Am J Med. Oct 1981;71(4):539-42. [Medline].

    35. Heilman CA. From the National Institute of Allergy and Infectious Diseases and the World Health Organization. Respiratory syncytial and parainfluenza viruses. J Infect Dis. Mar 1990;161(3):402-6. [Medline].

    36. Hockberger RS, Rothstein RJ. Varicella pneumonia in adults: a spectrum of disease. Ann Emerg Med. Aug 1986;15(8):931-4. [Medline].

    37. Hopewell PC, Luce JM. Pulmonary involvement in the acquired immunodeficiency syndrome. Chest. Jan 1985;87(1):104-12. [Medline].

    38. Klotman ME, Hamilton JD. Cytomegalovirus pneumonia. Semin Respir Infect. Jun 1987;2(2):95-103. [Medline].

    39. Leland DS, Emanuel D. Laboratory diagnosis of viral infections of the lung. Semin Respir Infect. Dec 1995;10(4):189-98. [Medline].

    40. Little JW, Hall WJ, Douglas RG Jr, Hyde RW, Speers DM. Amantadine effect on peripheral airways abnormalities in influenza. A study in 15 students with natural influenza A infection. Ann Intern Med. Aug 1976;85(2):177-82. [Medline].

    41. Mahmood W, Sacks SL. Anti-infective therapy for viral pneumonia. Semin Respir Infect. Dec 1995;10(4):270-81. [Medline].

    42. Pruitt RE, Gremillion DE, Herring RW, et al. Oral asacol in the treatment of mild to moderate ulcerative colitis: the Nashville experience. J Tenn Med Assoc. May 1991;84(5):237. [Medline].

    43. Ramsey PG, Fife KH, Hackman RC, Meyers JD, Corey L. Herpes simplex virus pneumonia: clinical, virologic, and pathologic features in 20 patients. Ann Intern Med. Dec 1982;97(6):813-20. [Medline].

    44. Shanley JD, Jordan MC. Viral pneumonia in the immunocompromised patient. Semin Respir Infect. Sep 1986;1(3):193-201. [Medline].

    45. Sullivan CJ, Jordan MC. Diagnosis of viral pneumonia. Semin Respir Infect. Jun 1988;3(2):148-61. [Medline].

    46. Wendt CH, Hertz MI. Respiratory syncytial virus and parainfluenza virus infections in the immunocompromised host. Semin Respir Infect. Dec 1995;10(4):224-31. [Medline].

    47. Wenzel RP, McCormick DP, Beam WE Jr. Parainfluenza pneumonia in adults. JAMA. Jul 17 1972;221(3):294-5. [Medline].

    48. Yuen KY, Wong SS. Human infection by avian influenza A H5N1. Hong Kong Med J. Jun 2005;11(3):189-99. [Medline].

    49. Zahradnik JM. Adenovirus pneumonia. Semin Respir Infect. Jun 1987;2(2):104-11. [Medline].

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    Keywords

    viral pneumonia, viral respiratory tract infections, influenza virus, respiratory syncytial virus, RSV, parainfluenza virus, PIV, Orthomyxoviridae, severe acute respiratory syndrome, SARS, avian influenza, swine flu

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    Contributor Information and Disclosures

    Author

    Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
    Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
    Disclosure: Nothing to disclose.

    Medical Editor

    Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
    Mark Raymond Wallace, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
    Disclosure: Nothing to disclose.

    Pharmacy Editor

    Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
    Disclosure: Nothing to disclose.

    CME Editor

    Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
    Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
    Disclosure: Nothing to disclose.

    Chief Editor

    Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
    Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
    Disclosure: Nothing to disclose.

     
     
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