Introduction

Acute upper respiratory tract infections (URTIs)

are a very common cause of:
• Morbidity.
• visits to doctors.
• absence from school or work.

They are the most common respiratory

complaint, accounting for about 9% of all
consultations in general practice.
Upper respiratory infections
• Common cold (Coryza)
• Pharyngitis
• Sinusitis
• Acute laryngitis
• Croup (acute LTB)
• Pertussis
• Acute Epiglottitis
• Influenza (seasonal or pandemic)
Common cold
It is transmitted by droplets, and characterized by:
• rhinorrhoea,
• sneezing,
• nasal obstruction and
• sore throat (pharyngitis),
• with minimal fever or systemic symptoms.
It may be caused by about 200 different strains of
viruses, including rhinovirus , coronaviruses,
respiratory syncytial, parainfluenza and influenza
viruses.
Common cold (continued)
secondary bacterial infection may occur,
• sinusitis,
• otitis media,
• bronchitis or
• pneumonia
Treatment is symptomatic:
Nasal decongestant
Paracetamol analgesic.
Pharyngitis
• Pharyngitis may occur as part of the common
cold or as a separate illness. Most cases are
caused by viruses (EB Virus ) but pharyngitis
may also be caused by
• group A 𝛃-haemolytic streptococci.
• Mycoplasma pneumoniae.
• Chlamydophila pneumoniae.
Pharyngitis (continued)
Complications :
• otitis media
• Tonsilliti.
• peritonsillar abscess.
• Glomerulonephritis. Rare
• Acute rheumatic fever.
Pharyngitis (continued)
Antibiotic treatment of pharyngitis is usually
only given to severe or complicated cases.
• Streptococci are sensitive to
phenoxymethylpenicillin or amoxicillin.
• Mycoplasma pneumoniae or Chlamydophila
pneu- moniae requires a tetracycline or
clarithromycin.
Sinusitis
organisms may cause sinusitis, including
• respiratory viruses,
• Haemophilus influenzae,
• Streptococcus pneumoniae
• Staphylococcus aureus
• anaerobic bacteria.
Sinusitis (continued)
• Infection of sinuses causes facial pain, nasal
obstruction and discharge, often accompanied
by fever and malaise.

• Post-nasal drip from chronic sinusitis is

irritating to the larynx and may cause a
persistent cough.
Sinusitis (continued)
• Recurrent sinusitis (may be accompanied by
bronchiectasis) is caused by:
• cystic fibrosis,
• hypogammaglobulinaemia
• ciliary dyskinesia.
Sinusitis (continued)
Sinusitis is usually treated with
• antibiotics (e.g. amoxicillin or trimethoprim),
• nasal decongestants (e.g. ephedrine) and
• analgesia (e.g. paracetamol).
• Surgical drainage may be necessary for relief
of chronic sinusitis.
Acute laryngitis
• Acute laryngitis is the most common cause of hoarseness,
which may persist for a week or so after other symptoms
of an upper respiratory infection have cleared.
• The patient should be warned to avoid vigorous use of the
voice (singing, shouting) until their voice returns to norma,
• since persistent use may lead to the formation of
traumatic vocal fold hemorrhage, polyps, and cysts.
• Although thought to be usually viral in origin, both M
catarrhalis and H influenzae may be isolated from the
nasopharynx at higher than expected frequencies.
• Erythromycin may speed improvement of hoarseness at 1
week and cough at 2 weeks when measured subjectively.
• Oral or intramuscular corticosteroids may be used in highly
selected cases of professional vocalists to speed recovery.
Croup (acute
laryngotracheobronchitis)
• It is usually caused by viruses such as
• parainfluenza virus,
• respiratory syncytial virus,
• influenza A and B,
• rhinoviruses,
• adenovirus and
• measles.
Croup (acute
laryngotracheobronchitis)
• The child develops a harsh barking cough and
stridor.
• Oral prednisolone is sometimes beneficial in
severe croup and nebulised high-dose
budesonide may be associated with more rapid
recovery in less severely affected patients.
• In severe cases when associated with
respiratory distress may need intubation and
mechanical ventilation.
Pertussis (whooping cough)
• It is an infectious disease of the respiratory
tract caused by Bordetella pertussis.
• the initial phase of the illness, there is nasal
discharge, pharyngitis and conjunctivitis. This
is followed by a severe cough, coughing end
with a deep inspiration (whoop).
• It is treated by clarithromycin.
Pertussis (continued)
• The incidence is greatly reduced by a
successful vaccination program for infants.
• Vaccine-induced immunity decreases after 5 –
10 years and pertussis can affect adults.
Acute epiglottitis
Epiglottitis is a very serious disease that is
usually caused by virulent strains of:
• Haemophilus influenzae type B, and there is
often an accompanying septicaemia.
• Death may result from occlusion of the airway
by the inflamed edematous epiglottis.
• It is most common in children of about 2–3
years of age, but cases have also occurred in
adults.
Acute epiglottitis (continued)
• The patient is ill with
• pyrexia,
• sore throat,
• laryngitis and
• painful dysphagia.
• Symptoms of upper airway obstruction may develop
rapidly, with
• stridor and respiratory distress.
• A lateral neck X-ray may show epiglottic swelling.
• Blood cultures often isolate Haemophilus influenzae
type B.
Acute epiglottitis (continued)
• Patients with suspected epiglottitis
• should be admitted to hospital and
• attempts at examining the upper airway
should only be made when facilities are
available for tracheal intubation and
ventilation.
• cefuroxime is an appropriate antibiotic.
• The widespread use of vaccination against
Haemophilus influenzae in childhood is making
epiglottitis increasingly rare.
Influenza

Seasonal Influenza
• Seasonal influenza is an acute illness
characterised by pyrexia, malaise, myalgia,
headache and prostration, as well as upper
respiratory symptoms. Lethargy and
depression may persist for several days
afterwards.
• Type A viruses are further divided into
subtypes based on the hemagglutinin (H) and
the neuraminidase (N) expressed on their
surface. There are 18 subtypes of hem-
agglutinin and 11 subtypes of neuraminidase.
Seasonal Influenza
(continued)
• Influenza virus type A undergoes frequent
spontaneous changes in its haemagglutinin and
neuraminidase surface antigens. Minor
changes, referred to as ‘antigenic drift’,
result in outbreaks of seasonal influenza in the
winter months each year.
Seasonal Influenza
(continued)
• Major changes, referred to as ‘antigenic
shift’, result in epidemics and pandemics of
infection, reflecting the lack of immunity in
the population to the new strain.
• Type B is more antigenically stable and
produces less severe disease.
• Type C causes only mild sporadic cases of
upper respiratory infection.
Seasonal Influenza
(continued)
• Clinical features
• After an incubation period of 1–3 days,
uncomplicated disease leads to fever, malaise
and cough. Viral pneumonia may occur,
although pulmonary complications are most
often due to superinfection with Strep.
pneumoniae, Staph. aureus or other bacteria.
Seasonal Influenza
(continued)
• Rare extrapulmonary manifestations include
myositis, myocarditis, pericarditis,
encephalitis and transverse myelitis.
• Mortality is greatest in the elderly, those with
medical comorbidities and pregnant women.
• Polymorphisms in the gene encoding an
antiviral protein, interferon-induced
transmembrane protein 3 (IFITM3), are
associated with more severe influenza.
Seasonal Influenza
(continued)
• The diagnosis of influenza can be confirmed by
immunofluorescent microscopy of nasal
secretions or by serology.

• Oseltamivir and zanamivir are drugs that reduce

the replication of influenza viruses by inhibiting
viral neuraminidase. Oseltamivir 75 mg twice
daily is given orally, whereas zanamivir 10 mg
twice daily is only available by inhalation,
duration of therapy is 5 days . These drugs have
to be given within 48 hours of the onset of
symptoms to be effective.
• Antiviral drugs can also be used as prophylaxis
in high-risk individuals during the ‘flu’ season.
Seasonal Influenza
(continued)
• Use of paracetamol relieves symptoms.
• Antibiotics are used when there are features
of secondary bacterial infection (e.g. otitis
media, sinusitis).
• Pneumonia associated with influenza may be
severe and requires treatment with broad-
spectrum antibiotics, including antibiotics
against Staphylococcus aureus (e.g. co-
amoxiclav, cefuroxime, flucloxacillin)
Seasonal Influenza
(continued)
• Vaccination remains the most effective way of
preventing illness from seasonal influenza.
However, if new pandemic strains of influenza
emerge, it will take time to develop vaccines.
Influenza vaccination
• The influenza vaccine is prepared annually
using the virus strains most likely to be
prevalent that year. The vaccine contains
inactivated virus and is about 70 – 80%
effective in protecting against infection.
Where infection occurs despite vaccination, it
is usually less severe and associated with less
morbidity and mortality than the disease seen
in unvaccinated patients.
Annual vaccination is recommended for:
• those over the age of 65 years,
• those with chronic respiratory disease (e.g. chronic
obstructive pulmonary disease, asthma, bronchiectasis etc.),
• chronic heart disease,
• renal failure,
• diabetes mellitus or
• immunosuppression and
• those living in care homes.
• Vaccination is recommended for pregnant women, as they are
at increased risk from complications of flu, and flu during
pregnancy is associated with premature births and reduced
birth size and weight.
• Vaccination during pregnancy also provides
passive immunity to infants in the first few
months of life.
• Vaccination is also recommended for
healthcare workers, to reduce the risk of their
contracting influenza and spreading the
infection to their patients, colleagues and
family members.
• Adverse reactions to influenza vaccine are
usually mild, consisting of fever and malaise in
some patients and local reactions at the site
of injection. The vaccine is contraindicated in
patients with egg allergy. Patients should be
advised that the vaccine will not protect them
from all respiratory viruses.
Pandemic influenza
• Pandemic influenza occurs when there are
major mutations in the virus that result in
increased virulence and a lack of immunity in
the population.
 Pandemic influenza
• Pandemic influenza have occurred
sporadically and unpredictably over the last
century. They arise when there are major
changes in the haemagglutinin (H) and
neuraminidase (N) surface antigens of the
influenza A virus. In 1918, a pandemic of
influenza caused by the H1N1 strain (Spanish
flu) killed about 30 million people worldwide.
• Avian influenza
• Avian influenza is caused by transmission of
avian influenza A viruses to humans.
• avian strain of influenza (H5N1) transmitted
from birds such as ducks and poultry to
humans. This has occurred mainly in South
East Asia and has produced severe influenza
pneumonia in humans, with a high death rate.
 Swine influenza

• Re-assortment of swine, avian and human

influenza strains can occur in pigs and lead to
outbreaks of swine ‘flu’ in humans, as
occurred in 2009, when an outbreak of
H1N1pdm2009 influenza spread around the
world from Mexico.
Common cold is characterized by the following, except

a) high Fever

b) sore throat

c) rhinorrhoea

d) sneezing

e) nasal obstruction

Answer: a
The following is not the complications of acute pharyngitis:

a) otitis media

b) tonsillitis

c) acute pyelonephritis

d) acute glomerulonephritis

e) acute rheumatic fever

Answer: c
A child presented to the ER with barking cough,
hoarseness of voice and stridor at 2 AM, which of the
following is appropriate:

a) promptly needs tracheostomy

b) broad spectrum antibiotic is essential

c) it is usually due Group A B-hemolytic streptococcus

d) steroid therapy is contraindicated

e) it is usually caused by viruses

Answer: e
Whooping cough is characterized by:

a) productive cough

b) wheezing

c) response to clarithromycin

d) chest pain

e) Stridor

Answer: c
Recognized features of COVID-19 are:

a) absence of fever

b) belongs to beta coronavirus Genus

c) minimal cough

d) large amount sputum

e) dramatic respond to high dose steroid

Answer: b