Article of interest: Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood.

Byars SG, et al. Association of Long-Term Risk of Respiratory, Allergic, and Infectious Diseases With Removal of Adenoids and Tonsils in Childhood. JAMA Otolaryngol Head Neck Surg. 2018 Jun 7.

In this study of almost 1.2 million children, of whom 17,460 had adenoidectomy, 11,830 tonsillectomy, and 31 377 adenotonsillectomy, surgeries were associated with increased long-term risks of respiratory, infectious, and allergic diseases. Although rigorous controls for confounding were used where such data were available, it is possible these effects could not be fully accounted for. Our results suggest it is important to consider long-term risks when making decisions to perform tonsillectomy or adenoidectomy.

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Nontypeable Haemophilus influenza infections

Langereis JD, de Jonge MI. Invasive Disease Caused by Nontypeable Haemophilus influenza. Emerg Infect Dis. 2015 Oct;21(10):1711-8.

The incidence of severe Haemophilus influenza infections, such as sepsis and meningitis, has declined substantially since the introduction of the H. influenzae serotype b vaccine. However, the H. influenzae type b vaccine fails to protect against nontypeable H. influenzae strains, which have become increasingly frequent causes of invasive disease, especially among children and the elderly. We summarize recent literature supporting the emergence of invasive nontypeable H. influenzae and describe mechanisms that may explain its increasing prevalence over the past 2 decades.

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Concurrent viral infections and Kawasaki disease

Song E, et al. Clinical and virologic characteristics may aid distinction of acute adenovirus disease from Kawasaki disease with incidental adenovirus detection. J Pediatr. 2016 Mar;170:325-30.

Incidental adenovirus detection in Kawasaki disease (KD) is important to differentiate from acute adenovirus disease. Twenty-four of 25 children with adenovirus disease and mimicking features of KD had <4 KD-like features, predominance of species B or E, and higher viral burden compared with those with KD and incidental adenovirus detection.

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Turnier JL, et al. Concurrent respiratory viruses and Kawasaki disease. Pediatrics. 2015 Sep;136(3):e609-14.

“Overall, our study supports earlier evidence that a large number of patients with KD have respiratory symptoms and evidence of viral nucleic acid in the nasopharynx. This study showed that a large percentage of patients with KD have a concurrent or recent history of respiratory viral infections and suggests that clinicians should not dismiss the diagnosis of KD based on the presence of respiratory or gastrointestinal symptoms or solely on the results of a positive respiratory viral PCR test. Furthermore, our data support the recommendation that a positive respiratory virus test result, regardless of the virus detected, should not be used to exclude the diagnosis of KD.4,16 Continued research is needed to elucidate the etiology and/or discover a more sensitive and specific diagnostic test for this important pediatric disease.”

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EBM Review: Clinical utility of PCR for common viruses in acute respiratory illness.

Rhedin S, Lindstrand A, Rotzén-Östlund M, et al. Clinical utility of PCR for common viruses in acute respiratory illness. Pediatrics. 2014 Mar;133(3):e538-45.

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BACKGROUND: Acute respiratory illness (ARI) accounts for a large proportion of all visits to pediatric health facilities. Quantitative real-time polymerase chain reaction (qPCR) analyses allow sensitive detection of viral nucleic acids, but it is not clear to what extent specific viruses contribute to disease because many viruses have been detected in asymptomatic children. Better understanding of how to interpret viral findings is important to reduce unnecessary use of antibiotics.

OBJECTIVE: To compare viral qPCR findings from children with ARI versus asymptomatic control subjects.

METHODS: Nasopharyngeal aspirates were collected from children aged ≤5 years with ARI and from individually matched, asymptomatic, population-based control subjects during a noninfluenza season. Samples were analyzed by using qPCR for 16 viruses.

RESULTS: Respiratory viruses were detected in 72.3% of the case patients (n = 151) and 35.4% of the control subjects (n = 74) (P = .001). Rhinovirus was the most common finding in both case patients and control subjects (47.9% and 21.5%, respectively), with a population-attributable proportion of 0.39 (95% confidence interval: 0.01 to 0.62). Metapneumovirus, parainfluenza viruses, and respiratory syncytial virus were highly overrepresented in case patients. Bocavirus was associated with ARI even after adjustment for coinfections with other viruses and was associated with severe disease. Enterovirus and coronavirus were equally common in case patients and control subjects.

CONCLUSIONS: qPCR detection of respiratory syncytial virus, metapneumovirus, or parainfluenza viruses in children with ARI is likely to be causative of disease; detection of several other respiratory viruses must be interpreted with caution due to high detection rates in asymptomatic children.

Reviewed by: 

Liesl Windsor, MD Liesl Windsor, MD

Neil Cella, MD Neil Cella, MD

A clinical scenario:

  • 18 month old male ex 27 weeks with h/oCLD, developmental delay, and G-tube presenting with:
    • 3 days fever
    • Very worried caregivers – last respiratory illness ended up as intubation
    • Runny nose, cough and emesis
    • Increased oxygen requirement from ¼ LPM to 1 LPM
    • Less active and more fussy, attends medically fragile daycare
    • Exam – TMs clear, nasal congestion, normal cardiac exam, mild tachypnea, no retractions, no wheeze, crackles bilaterally, no focally decreased breath sounds
    • CXR – RUL atelectasis versus focal pneumonia
    • Admitted for hypoxia –  ED sent VRP and it has come back positive for Adenovirus. Does this help in antibiotic decision making on admission?


  • Matched Case-Control Study
    • Cases – children aged less than or equal to 5 years with one or more of the following:
      • Coryza, sore throat, earache, cough, sputum production, or dyspnea
      • Only included in study once; enrolled from September 2011 to January 2012
    • Matched controls
      • According to calendar time(+ or – 14 days) and age(+ or – 6 months)
      • Enrolled from local swedish vaccination program
      • Excluded if reports of respiratory disease in prior 7 days
      • If no match found, controls expanded to +/- 30 days and +/- 12 months

What do we think of this study design?

  • These authors have used this phrase “case-control” study, but it is more of a cohort
  • Advantages – practical and affordable
  • Disadvantages – retrospective nature, difficult to match control group

Strengths of study:

  • Observational design
  • Attempted to match
  • Sample size?
  • Impact of journal
  • Clinically relevant

Weaknesses of study:

  • Observational Design – unable to choose the patients that will be affected
  • Compared two different groups
    • Controls were younger and more frequently female; less attended day care; more breast fed; less had asthma; less were being treated with antibiotics; less were children of higher educated parents
  • No follow up – early detection in controls? Asymptomatic carriage? No microbiological investigation for bacteria
  • Qualitative versus quantitative PCR

Return to case and further questions:

  • In this study, adenovirus detection in cases did not differ significantly from controls
  • We can only apply results to diagnosis and all management questions are not related to this study
  • Still, would Adenovirus positivity stop us from treating him for bacterial super-infection?
  • If he was Parainfluenza+ or co-infected, would this stop us from treating him for super-infected pneumonia?
  • Is there value in a diagnosis beyond management? Very worried parents? Epidemiology at an academic center?
  • Will cost come down with time?

Practice Based Learning: Adenovirus: to treat or not to treat.

Asmaa Ferdjallah, MD

Presented by Asmaa Ferdjallah, MD

Do we treat kids with adenovirus?

  • Who is particularly at risk?
    • Solid-organ and bone marrow transplant recipients
    • Neonates
    • Children with immunodeficiency
  • Case fatalities are as high as 50-80% in immunocompromised children.
  • Immunocompetent children rarely develop severe adenovirus disease.
  • Do not forget potential adverse reactions of Ribavirin or Cidofovir.

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Practice Based Learning: Does testing with respiratory viral panel change management in hospitalized patients?

Jill Euteneuer, MD

Presented by Jill Euteneuer, MD

Key points:

  1. Rhinovirus/enterovirus, RSV and Influenza A are most commonly isolated pathogens
  2. No significant difference in length of stay or duration of antibiotic therapy

Bottom line:

While possibly useful for epidemiologic purposes, there is no conclusive evidence to suggest that obtaining a respiratory viral panel will change management of hospitalized patients


Huijskens, E. G. et al. “Diagnostic value of respiratory virus detection in symptomatic children using real-time PCR.” Virology Journal 9 (2012). Web. 9 December 2012.

Van der Zalm, M et al. “Respiratory pathogens in respiratory tract illnesses during the first year of life.” The Pediatric Infectious Disease Journal. 28 (2009): 472-476. Web. 9 December 2012.

Van der Zalm, M et al. “Respiratory pathogens in children with and without respiratory symptoms.” Journal of Pediatrics 154 (2009): 396-400. Web. 9 December 2012.

Van de Pol, A et al. “Increased detection of respiratory syncytial virus, influenza viruses, parainfluenza viruses, and adenoviruses with real-time PCR in samples from patients with respiratory symptoms.” Journal of Clinical Microbiology 45 (2007): 2260-2262. Web. 9 December 2012.

Van Benten, I et al. “Predominance of rhinovirus in the nose of symptomatic and asymptomatic infants.” Pediatric Allergy and Immunology 14 (2003): 363-370. Web. 9 December 2012.

Wishaupt, J et al. “Clinical Impact of RT-PCR for Pediatric Acute Respiratory Infections: A controlled clinical trial.” Pediatrics 128 (2011): e1113-e1120. Web. 9 December 2012.