NR507 W1TD1 Upper Respiratory Infection

NR507 W1TD1 Upper Respiratory Infection

NR507 W1TD1 Upper Respiratory Infection

John is a 19-year-old college football player who presents with sneezing, itchy eyes, and nasal congestion that worsens at night. He states that he has a history of asthma, eczema and allergies to pollen. There is also one other person on the football team that has similar symptoms. His vitals are BP 110/70, P 84, R 18, T 100 F.

Write a differential of at least three (3) possible items from the most likely to less likely. For each disease include information about the epidemiology, pathophysiology and briefly argue why this disease fits the presentation and why it might not fit the presentation.

Differential:

1. Upper Respiratory Infection (Viral/Bacterial)

Upper respiratory infection is the most common diagnosis among children and adults that contribute to around 30 million office visits annually (Domino, 2017). Rhinoviruses infects the ciliated epithelial mucosa of the upper airway resulting in edema, hyperemia, and mucus production. Inflammation of the nasal passages and nasal congestion is a result of mucosal edema, following vascular engorgement and inflammatory infiltration (containing neutrophils, plasma cells, lymphocytes and basophils). Symptoms are due to the immune response to infection (viral). Fever, when present, tends to be low grade.

The pathology of URI includes:

• Edema of sub epithelial connective tissue and a cellular infiltrate made up of neutrophils, plasma cells, lymphocytes, and eosinophils
• Rhinovirus causes a nondestructive inflammatory response of the mucous membranes
• Influenza and parainfluenza strips respiratory epithelium to the basement membrane.
• Multiple viral strains from different families can cause an URI
  • Rhinovirus
  • Influenza virus
  • Coronaviruses
  • Parainfluenza and respiratory syncytial virus (RSV) is more common in children
  • Enteroviruses and adenoviruses

The symptoms of URI vary but can include rhinorrhea, edema and inflammation of the nasal mucosal, nasal congestion, sneezing, cough, sore throat, and low grade temperature. Exposure to those infected, allergic disorders, stress, and immunosuppression increase the risk of contracting the virus. Most cases are mild to moderate and self-limiting. Most infections occur during winter months and symptoms usually peak in about 3 days and can last for up to 2 weeks. Given that John and one of his teammates exhibit some of the same symptoms an URI could be the cause.

1. Seasonal allergic rhinitis/hay fever

There is a seasonal pattern to the patient’s symptoms that include sneezing, itchy eyes, and nasal congestion that is worse at night. Given his past medical history of asthma, eczema and allergies to pollen suggests a humoral immunity. Primary exposure to an allergen causes T cells to recognize the allergen as foreign and release chemicals that signal B cells to produce specific antibodies called IgE which attach to mast cells. These mast cells can remain in the body for years ready to react if exposure to allergen occurs again.

The pathology of allergic rhinitis includes:

• Surface-bound IgE on nasal mucosa is bound by the inciting antigen-antibody response
• Mast cells and basophils are activated by inflammation
• Histamine is released as a mediator of the immediate inflammatory response triggering sneezing, nasal secretions, and nasal constriction. These are early phase responses to antigens
• The last phase of the immune response involves the influx of eosinophils and mononuclear cells, peaking at 6 to 12 hours after exposure
• The main symptoms of this response are erythema, itching, burning, and heat

The symptoms worsen at night, which is due to lower levels of the hormone cortisol (which is highly ant-inflammatory). Cortisol levels vary during the day; they are lowest in the evening, which explains why most inflammatory reactions worsen at night (Hill, Grundmeier, Ram, & Spergel, 2016).

• Influenza (Flu)

The flu is a contagious respiratory illness caused by 4 types of myxoviruses that infect the nose, throat, and lungs (McCance, Huether, Brashers & Rote, 2013). It can cause mild to severe illness including death. Symptoms include fever, inflamed mucosal membranes, headache, malaise, body aches, and sometimes gastrointestinal irritation (Duncan, 2013).

The pathology of Influenza includes:

• Influenza virus is an enveloped negative-strand RNA virus with segmented genomes containing seven to eight gene segments.
• Influenza virus is designated A, B, C or D. Type A and B causes seasonal epidemics of disease almost every winter in the United States. Type B and C viruses are found mostly in humans, although type B and C have been isolated from pigs and dogs. Influenza type C infections generally cause a mild respiratory illness and are not thought to cause epidemics. Type D viruses primarily affect cattle and are not known to infect or cause illness in people.
• Influenza A viruses can be found in birds, swine, horses, humans, and other mammals. Influenza A viruses are subdivided by antigenic characterization of the hemagglutinin (HA) and NA surface glycoproteins that project from the virion.
• Influenza A and B viruses are the most common causes of influenza-like illness (ILI), but other pathogens also cause ILI, including influenza C viruses, parainfluenza viruses, respiratory syncytial viruses, and Mycoplasma pneumoniae.
• Influenza virus replicates in the epithelial cells throughout the respiratory tree

Flu can be excluded in the absence of systemic symptoms, cough, fatigue, and inability to perform ADLs. Although it is highly unlikely that John has the flu, but given the fact that he has been in close contact with others that exhibit the same symptoms in the presence of low grad fever, testing would not cause undue harm.

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NR507 W1TD1 Upper Respiratory Infection

Reference

Domino, F. (2017). The 5-Minute Clinical Consult Premium 2017. Retrieved April 30, 2017 from https://www-r2library-com.proxy.chamberlain.edu:8443/Resource/Title/1496339975

Domino, F. (2017). The 5-Minute Clinical Consult Premium 2017. Retrieved April 30, 2017 from https://www-r2library-com.proxy.chamberlain.edu:8443/Resource/Title/1496339975

Duncan, D. (2013). Treatment and prevention of influenza. Nurse Prescribing, 11(12), 590- 596. Retrieved from http://www.markallengroup.com/ma-healthcare/

Hill, D. A., Grundmeier, R. W., Ram, G., & Spergel, J. M. (2016). The epidemiologic characteristics of  healthcare provider-diagnosed eczema, asthma, allergic rhinitis, and food allergy in children: a retrospective cohort study. BMC Pediatrics, 161-8. doi:10.1186/s12887-016-0673-z

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.