By Prof DR Hanan Ibrahim

A 6 years old previously healthy boy with

extensive pneumonia.

Rapidly progressing ARDS.

CRP and CBC shows no signs of bacterial

sepsis.

Leucopenia, lymphopenia.
Bacterial Pneumonia:
CRP-ve
CBC parameters
No response to aggressive
antibiotic therapy
Fungal Pneumonia:
The patient is
immunocompetent
The patient has no history of
recurrent or chronic chest
problems
Atypical Pneumonia
The "atypical" bacteria are Coxiella burnetti,
Chlamydophila pneumoniae , Mycoplasma pneumoniae ,
and Legionella pneumophila.
They are "atypical" because they commonly affect
teenagers and young adults, are less severe, and require
different antibiotics than typical bacteria such as
Streptococcus pneumoniae.
Viral Pneumonia
Flu preceding pneumonia
V. raped course
CBC parameters
No response to antibiotics
Viruses that commonly cause pneumonia include:
Influenza virus A and B
(Avian Flu, Swine Flu)
Respiratory syncytial virus (RSV)
Adenoviruses (in military recruits)
Metapneumovirus
Human parainfluenza viruses (in children)
Corona Virus (SARS)
Hanta Virus
Rhino Virus
Viruses that rarely cause pneumonia include:
Herpes simplex virus (HSV), mainly in newborns
Varicella-zoster virus (VZV)
Cytomegalovirus (CMV), mainly in people with immune system
problems
Viruses account for the largest proportion of
childhood pneumonia; viruses decrease in
frequency as the etiology of pneumonia in healthy
adults, and once again become frequent causes of
death and morbidity in persons older than 60
years.
Viral pneumonia can vary from a mild illness to a
life-threatening disease with respiratory failure,
severe hypoxemia, and ARDS.
Viruses associated with severe
pneumonia and ARDS
-Influenza Virus
-Corona Virus(SARS)
-Adeno Virus
-Metapneumovirus
-Hanta Virus
Human Metapneumovirus
HMNV,a respiratory virus identified in 2001, is
emerging as one of the most common causes of
serious lower respiratory tract illness in children
allover the world.
It belongs to Paramyxoviridae family.
HMNV outbreaks in annual epidemics (late winter
and early spring ).
C.P. is similar to the profile of RSV.
Young age is a major risk of severe illness.
Adenovirus
Adenoviruses are medium-sized (90-100 nm),
nonenveloped icosohedral viruses containing double-
stranded DNA.
There are 51 immunologically distinct types (6
subgenera: A through F) that can cause human
infections.
Clinical Syndromes by Adenoviruses
-Acute Respiratory Disease
Pharyngitis
Pneumonia
pertussis-like syndome
pharyngoconjunctival fever
-Conjunctivitis and keratoconjunctivitis(Pink Eye Syndrome)
-Myocarditis
-Gastrointestinal Infections
-Hemorrhagic cystitis
-Reye Syndrome and Reye-like Syndrome
Severe Pneumonia and ARDS
are most often associated with
adenovirus types 3, 7,and 21 .
Such infections have high
mortality, and residual airway
damage.
Killer Cold Virus: Adenovirus Infection (Ad14)

A rare strain of a cold virus, known as adenovirus type 14

(Ad14), has caused severe and even fatal respiratory
illness in healthy children and adults.

Infection with the virus seems to be becoming more

common in the United States, according to officials from
the U.S. Centers for Disease Control and Prevention
(CDC).
This virus is different from other adenoviruses that cause
the common cold in that it may produce an unusually
severe illness requiring intensive medical care.
Although the Ad14 strain was identified in the 1950s, the
variant that was isolated in 2006 and 2007 is genetically
different from the original Ad14, suggesting that the viral
genetic material has undergone mutations (changes)
that have resulted in the increased severity of infections
with Ad14.
Severe acute respiratory
syndrome
SARSis a respiratory disease in humans which is caused by the
SARS coronavirus (SARS-CoV).There has been one near pandemic
to date, between the months of November 2002 and July 2003,
with 8,096 known infected cases and 774 deaths (a case-fatality
rate of 9.6%) worldwide being listed in the World Health
Organization's (WHO) 21 April 2004 concluding report.

Within a matter of weeks in early 2003, SARS spread from the

Guangdong province of China to rapidly infect individuals in some
37 countries around the world.
As of May 2006, the spread of SARS has been
fully contained thanks to the efforts of the WHO,
with the last infected human case seen in June
2003 (disregarding a laboratory induced infection
case in 2004).
However, SARS is not claimed to have been
eradicated (unlike smallpox), as it may still be
present in its natural host reservoirs (animal
populations) and may potentially return into the
human population in the future.
Influenza Viruses
Influenza, commonly referred to as the flu, is an
infectious disease caused by RNA viruses of the family
Orthomyxoviridae(the influenza viruses), that affects
birds and mammals.
Types of Influenza virus:
Influenza virus A
Influenza virus B
Influenza virus C
Isavirus
Thogotovirus
Influenza A
Influenza A is responsible for
human pandemic outbreaks and
seasonal epidemics
Influenza A viruses are classified
into subtypes on the basis of the
antigenic properties of the
hemagglutinin and neuraminidase
glycoproteins expressed on the
surface of the virion . To date, 16
hemagglutinin and 9 neuraminidase
subtypes have been identified and
are found in 144
different combinations (e.g., HlNl,
H3N2, H5N1, etc.) .
Antigenic drift
Antigenic drift is due to mutation. Antibodies to the HA protein
are the most important in protection, although those to NA also
play a role. Both proteins undergo antigenic drift (i.e. accumulate
mutations) and accumulate changes such that an individual
immune to the original strain is not immune to the drifted one.
Antigenic drift results in sporadic outbreaks and limited
epidemics.
Antigenic shift
Antigenic shift is due to reassortment. In the case of influenza
A, antigenic shift periodically occurs. Apparently "new" HA
and/or NA are found in the circulating viral strains. There is little
immunity (particularly if both proteins change, or if new HA is
present) and an epidemic/pandemic is seen.
H1N1, which caused Spanish flu in 1918, and Swine flu in
2009
H2N2, which caused Asian Flu in 1957
H3N2, which caused Hong Kong Flu in 1968
H5N1, a pandemic threat in the 2007–08 flu season
H7N7, which has unusual zoonotic potential
H1N2, endemic in humans and pigs
H9N2
H7N2
H7N3
H10N7
105
 Avian Flu
Human influenza pandemics over the last 100 years have
been caused by H1, H2,and H3 subtypes of influenza A
viruses.
More recently, avian influenza viruses have
been found to directly infect humans from their avian
hosts.
The recent emergence, host expansion, and spread of a
highly pathogenic avian influenza (HPAI) H5N1
subtype in Asia has heightened concerns globally, both in
regards to mortality ofHPAI H5N1 in humans and the
potential of a new pandemic
Since the first H5N1 outbreak occurred in 1997, there
has been an increasing number of HPAI H5N1 bird-to-
human transmissions leading to clinically severe and
fatal human infections.
Although millions of birds have become infected with
the virus since its discovery, 248 humans have died from
the H5N1 in twelve countries according to WHO data as
of January 2009.
Epidemiologists are afraid that the next time such a virus
mutates, it could pass from human to human. If this
form of transmission occurs, another pandemic could
result.
How Human Get Infection ?
Close contact with bird
secretions or blood
Clinical Manifestations of
Avian Influenza in Humans
While the ages of the patients have varied, the majority of
casesin both the 1997 and 2003 HPAI the were young.

Incubation period ranged from 2 to 8 days .

Case fatality rate is 68%-80% in human and 100% an birds.

The clinical manifestations of avian influenza in humans have
ranged from mild conjunctivitis to severe pneumonia with
multiple organ failure (MOF)

The main presenting symptom is pneumonia with fever and an

influenza-like illness. Diarrhea was present in upto 70% of the
cases.
Many cases had both thrombocytopenia and lymphopenia.
Chest radiographic findings included interstitial infiltrates, lobar
consolidation, and air bronchograms.

Sixty-eight percent of patients developed ARDS and MOF within

6 days of disease onset.
The average time of death from disease onset was 9–10 days.
Diagnosis
The clinical diagnosis of avian influenza
infection in humans is difficult and relies
on the epidemiological link to endemic
areas, contact with sick or dead poultry, or
contact with a confirmed case of avian
influenza.
Polymerase Chain Reaction (PCR)
on clinical samples with primers specific for
the viral subtype.
Treatment
Antiviral therapy, Supportive
care, and Adjunctive therapies
Antiviral Therapy
The adamantanes (rimantadine and amantadine) Adamantanes bind
to the M2 protein on the viral capsule, HPAI H5N1 isolated from
Southeast Asia carriedthe mutation in M2 that conferred resistance to
this group of antivirals

Neuraminidase inhibitors (oseltamivir and zanamivir) The timing of

treatment is paramount, as earlier therapy is directly related to
improved survival. The greatest level of protection was seen if the
neuraminidase inhibitors were started within 48 hours of infection,
and protection rapidly dropped after 60 hours.
For oseltamavir, therapy has been at75 mg twice daily, with 75 mg
once daily reserved for prophylaxis.

Zanamivir is available in a dry powder inhalation at 10 mg twice daily

for treatment and 10 mg daily for prophylaxis.
Vaccination
Not yet available
Infection Control and
Preventative Measures
World Health Organization (WHO) and Centers for Disease Control
and Prevention (CDC) recommend contact and airborne
precautions for any initial suspected case of avian influenza in a
human.
-Use of masks and respirators in the health care setting
In certain high risk procedures,additional protection with
an N-95 particulate respirator may be considered .

-Impermeable gown, face shield, and gloves.

-Initial cases should be placed in a negative pressure

isolation room with 6-12 air changes per hour.

-Hand hygiene with antibacterial soap or alcoholbased

washless gel should be standard, with appropriate basins
at each patient room.
Infection control measures are the mainstay for
prevention and disease reduction. Avian influenza
viruses may constitute part of the
next pandemic, so appropriate knowledge,
prevention, and treatment will reduce the
likelihood of this occurrence.
Thank you