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Respiratory Syncytial Virus (RSV)

Clinical Patient Case Study

Introduction

Respiratory Syncytial Virus (RSV) is a virus that most commonly infects young children

and is increasingly becoming a more common pathogen in adults, especially the elderly. 1

Virtually, 90% of children contract RSV infection by the age of two and then become reinfected

later in life due to the fact that humans lack long-term immunity post-infection, which makes

reinfections numerous. In the United States, RSV is attributed to over 57,000 hospitalizations,

500,000 visits to the emergency department, and 1.5 million visits to outpatient clinics for

children younger than the age of five every year.2 Also, among children younger than the age of

five, there is an estimate of 100-500 of RSV-associated deaths annually. Furthermore, it is

estimated that RSV infections cause 177,000 hospitalizations and 14,000 deaths for adults2 that

are 65 years and older in the United States each year.3

RSV is a respiratory virus that enters the body through the mouth, nose, or eyes4 and then

infects the nasal cavity, throat, lungs, and breathing passages.3 RSV is transmitted via respiratory

droplets from infected individuals or touching contaminated fomites. Additionally, RSV can

survive on hard surfaces, such as cribs, for several hours and can live on soft surfaces, such as

hands, for a shorter amount of time. RSV infection typically circulates during the fall and winter

months5; however, the COVID-19 pandemic has affected the normal transmission pattern of

RSV, causing an influx of out of season infections.3 In early 2021, many US states reported

activity of RSV infections in summer and spring seasons.6 The estimated incidence for RSV

hospitalizations among children one year of age during the RSV seasons of both 2021 and 2022
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was 707 per 100,000 children, this is compared to a typical RSV season of 355 per 100,000

children annually.

Most often RSV presents as an upper respiratory illness, but it does have the possibility

of becoming involved in the lower respiratory tract, causing a more severe infection.1

Symptoms for an RSV infection generally start four to six days post-exposure and then gradually

develop over the next several days.5 Generally, RSV causes signs and symptoms similar to a

cold, which includes congestion, cough, sore throat, headache, sneezing, and low-grade fever.4

However, in more severe cases of RSV, signs and symptoms include rapid or difficulty

breathing, wheezing, cyanosis, fever, middle ear infections, bronchiolitis, pneumonia and severe

cough. Additionally, infants with a severe RSV infection will show symptoms of poor feeding,

lethargy, and irritability. Typically, the contagious period of RSV lasts about ten days after

symptoms begin, though in some cases symptoms can last longer.5 Symptoms, such as repeated

wheezing and cough, can persist for weeks after recovery from infection.4,5

Those who are at an increased risk for a severe RSV infections or complications include,

infants, specifically premature infants or infants that are six months or younger, children or

adults with immunosuppressive disorders, those with neuromuscular disorders, older individuals,

notably those who are 65 years or older, and those with heart or lung diseases.5 Studies suggest

that those who acquired a severe RSV infection in their first three years of life generally are

more at risk for developing long-term complications.7 These long-term complications include

continuous wheezing and asthma. After having bronchiolitis with an RSV infection, one-third or

more of children will experience recurrent wheezing.8 Both long-term complications seem to

occur due to viral injury to lungs, preexisting impaired lung function, and other factors that
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predispose one to recurrent wheezing and or asthma, such as genetics and exposure to tobacco

smoke.7

Illustrative Case Description

The patient was a five-week old female that was brought into the clinic by her parents

due to respiratory distress. The baby was a first time patient at the clinic, so no prior medical

history was known before the appointment. During the examination, the parents were clearly

anxious and stated that the baby’s symptoms had started two days prior to the appointment. The

parents also stated that the baby had no fevers since symptoms started. The parents shared that

the baby likely had an RSV infection because their eldest child had an ongoing RSV infection.

The mother, who was currently breast-feeding, expressed that the baby's appetite had decreased.

Additionally, the parents said that they used an owlet sleep monitor and during the previous

night, the baby’s oxygen saturation went from 99% to 93%.

During the respiratory examination, the baby did have a croup cough, an audible grunt

with respiration, and minorly distressed breathing sounds. Also, the baby was irritable and did

show signs of excess mucus production. Examination of the baby’s ears showed that both ear

canals were clear and showed no signs of fluid pressure. The baby’s heart rate was normal and

upon palpation the baby’s abdomen was nondistended and soft. An oral examination showed no

redness or inflammation of the baby’s throat.

The parents were advised to confirm RSV diagnosis with a swab and to get a chest x-ray

to ensure lungs are clear. Additionally, parents were encouraged to start supplementing Pedialyte

in a bottle for the baby and to supply the baby with humidity, either through the use of a

humidifier or steam from a hot shower, to aid with the cough and loosen the mucus. The baby
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and parents were sent down to outpatient on the hospital side for vitals to be taken since the baby

was so young and accurate vitals were hard to obtain in the clinic with the available equipment.

The results from the baby’s swab came back as RSV positive. Also, the chest x-ray came

back as negative, meaning lungs were clear. The baby’s vital signs in the outpatient were stable,

with the baby's oxygen saturation was anywhere from 93% to 100%, blood pressure was 90/60,

heart rate was 130 bpm, and respiration rate was 30-60 times per minute. Due to the parents

being visibly nervous, the baby was admitted to inpatient for overnight observation. Baby was

given breathing treatments as needed throughout the night and the baby was cleared the next

morning to return home.

Discussion

Since RSV has similar signs and symptoms to many respiratory illnesses, such as

influenza and COVID-19, clinical laboratory test are needed to confirm RSV diagnosis.9 The

most common RSV clinical laboratory tests used are real-time reverse transcriptase-polymerase

chain reaction (rRT-PCR) and antigen testing. For infants and children, rRT-PCR and antigen

testing are both effective in diagnosing RSV infection; however, antigen testing is usually

preferred for this age group. The sensitivity range of an antigen test for infants and children is

80%-90%. For older children and adults, most healthcare providers typically use rRT-PCR since

they are a highly sensitive test. Antigen testing is generally not effective for this age group due to

older children and adults sometimes having low viral load in their respiratory samples. Other

tests used to diagnose RSV infections include viral cultures and serology, though these tests are

less commonly used. While clinical laboratory tests can help diagnose and rule out any other

illness that may be causing the symptoms, it is not always needed.10 Many physicians may
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suspect an RSV infection based on the time of year in which symptoms occur and upon physical

examination.

RSV treatment can be divided into three categories, which include supportive care,

immune prophylaxis, and antiviral medication.1 Supportive care is the most common treatment

for patients with an RSV infection and generally consists of additional hydration to prevent

dehydration, over the counter antipyretics for fever, suction or lubrication for nasal congestion

relief, and oxygen in cases of hypoxia. Immune prophylaxis exists in the form of the antiviral

drug palivizumab, which provides effective passive immunity for RSV. Palivizumab is

expensive1 and limited, so it is typically only recommended for infants that are at high-risk for

severe RSV infections.3 There is one antiviral medication that has been approved in the United

States to be used against RSV infection and it’s called Ribavirin.1 However, Ribavirin use is

evaluated case by case and discouraged for routine treatment.

Since there is no vaccine for RSV, many prevention methods consist of lifestyle habits to

prevent infection.4 Frequently washing hands and keeping items such as tabletops, door handles,

and toys clean are easy and effective ways to stop the spread of RSV. Also, covering the mouth

and nose when sneezing, making sure to not share drinking cups with others, and avoiding

contact with those who have colds or fevers can limit the spread. Additionally, if signs and

symptoms of RSV are present, stay home and if possible isolate from others until symptoms have

subsided.5 Precautionary measures such as wearing a mask in crowded settings and social

distancing can help reduce the spread of RSV.

Conclusion

Respiratory syncytial virus (RSV) is a very common respiratory illness in young

children5, with virtually 90% of children being infected with RSV by the age of two.2 RSV is
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also becoming a more prevalent pathogen in adults, especially the elderly.1 For infants, young

children, and older individuals, RSV is the main cause for acute respiratory hospitalizations 6,

with over 57,000 hospitalizations for those younger than the age of five and 177,000

hospitalizations2 for individuals who are 65 or older.3 RSV is generally an upper respiratory

infection1 that presents with cold-like symptoms4; however, RSV does have the potential to

travel to the lower respiratory system and cause a more severe infection.1 Those who acquire a

severe RSV infection in their first three years of life are at risk for long-term complications, such

as recurrent wheezing and asthma.7 Since signs and symptoms for RSV are similar to many

respiratory illness, clinical laboratory testing such as antigen testing and rRT-PCR are used to

confirm RSV diagnosis.9 There are three categories of treatment for RSV infection: supportive

care, immune prophylaxis, and antiviral medication.1 Since there is no vaccine for RSV, many

prevention method include lifestyle habits such as handwashing and keeping frequently touched

items clean.4 Isolating when sick, wearing a mask in public setting, and social distancing are all

precautionary measures that can be taken to aid in the prevention of the spread of RSV. 5
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References

1. Jain H, Schweitzer JW, Justice NA. National Library of Medicine. “Respiratory

Syncytial Virus Infection.” 21 Jun 2022. https://www.ncbi.nlm.nih.gov/books/NBK4
59215/ Accessed November 20, 2022
2. Centers for Disease Control and Prevention. “Respiratory Syncytial Virus-Associated
Mortality (RSV-Associated Mortality) 2019 Case Definition.” 16 Apr 2021. https://ndc.
services.cdc.gov/case-definitions/respiratory-syncytial-virus-associated-mortality-2019/
Accessed November 20, 2022
3. National Foundation for Infectious Disease. “Respiratory Syncytial Virus (RSV).” Feb
2022. https://www.nfid.org/infectious-diseases/rsv/ Accessed November 20, 2022
4. Mayo Clinic. “Respiratory Syncytial Virus (RSV): Symptoms and Causes.” https://www.
mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/symptoms-causes/syc-
20353098 Accessed November 20, 2022
5. New York State Department of Health. “Respiratory Syncytial Virus (RSV) Infection.”
https://www.health.ny.gov/diseases/communicable/respiratory_syncytial_virus/
#:~:text=Symptoms%20generally%20begin%20four%20to,to%20a%20number%20of
%20weeks Accessed November 20, 2022
6. Zheng Z, Pitzer VE, Shapiro ED, Bont LJ, Weinberger DM. National Library of
Medicine.“Estimation of the Timing and Intensity of Reemergence of Respiratory
Syncytial Virus Following the COVID-19 Pandemic in the US.” 16 Dec 2021.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8678 706/ Accessed November 20, 2022
7. Fauroux B, Simões EAF, Checchia PA, Paes B, Figueras-Aloy J, Manzoni P, Bont L,
Carbonell-Estrany X. National Library of Medicine. “The Burden and Long-term
Respiratory Morbidity Associated with Respiratory Syncytial Virus Infection in Early
Childhood.” 29 Mar 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446
364/#:~:text=In%20addition%20to%20the%20acute,sensitization
%20%5B10%E2%80%9312%5D Accessed November 20, 2022
8. Zhou Y, Tong L, Li M, Wang Y, Li L, Yang D, Zhang Y, Chen Z. National Library of
Medicine. “Recurrent Wheezing and Asthma After Respiratory Syncytial Virus
Bronchiolitis.” 4 Jun 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211724
/#:~:text=In%20our%20research%2C%20the%20incidence,after%20bronchiolitis
%20with%20RSV%20infection Accessed November 23, 2022
9. Centers for Disease Control and Prevention. “Respiratory Syncytial Virus Infection
(RSV).” 28 Oct 2022. https://www.cdc.gov/rsv/clinical/index.html Accessed November
24, 2022
10. Mayo Clinic. “Respiratory Syncytial Virus (RSV): Diagnosis and Treatment.” https://w
ww.mayoclinic.org/diseases-conditions/respiratory-syncytial-virus/diagnosis-treatment/
drc-20353104 Accessed November 24 , 2022