CHAPTER XII VIRAL INFECTIONS OF THE RESPIRATORY TRACT Eacit year, with the arrival of cold weather, viral infections of the respiratory {ract build up to form a hard core of minor winter ailments, They may form ss much as a third of a general practitioner's day-to-day work. Most of the Patients recover within a few days but secondary bacterial infection may often follow with such severe complications as bronchopneumonia, sinusitis or otitis media, ‘Syndromes Viruses - Catarrh of the nasal passages. Rhinoviruses Common cold. Sinusitis (@) H strains (about 50 serotypes) (8) M strains (7 known serotypes) Coxsackie A 21 (Coe) Coxsackie B3 Parainfluenza viruses 1-4 Respiratory syneytial virus Adenoviruses Mycoplasma pneumoniae . Febrile catarth of the upper respiratory tract (a) Non-exudative pharyngitis Adenoviruses types 1, 2, 3 and 5 (2) Pharyngoconjunctival fever Adenoviruses 3, 7a, 12, 8, 6 and 14 (©) Acute laryngitis Adenoviruses 4, 7, 3 and 14 (@ Croup (obstructive laryngo- _Para-inluenza viruses types 1,2 and 3 & tracheo-bronchitis) Adenoviruses types I, 2, 3,4, 5, 7and 7a (©) Influenza, Acute bronchitis _Inftuenza viruses A, B and C Involvement of lower respiratory tract Respiratory syneytial virus Adenoviruses types 1, 3, 4, 7 and 7a Influenza viruses A, B and C Bronchiolitis. Pneumonitis, |. Primary atypical pneumonia Adenoviruses (a) infants 7a, 1 and 3 (6) adults 4, 7 and 3 Respiratory syneytial virus Rickettsia burnetii (Q fever) Paittacosis organism Influenza and para-influenza viruses Mycoplasma pneumoniaeCLINICAL VIROLOGY The viruses associated with respiratory disease change continually in their pathogenic qualities and epidemic potentialities so that each year unfamiliar strains emerge and are able to find many inexperienced susceptible hosts in the community. The relationship between the many virus types and the clinical features of diseases cannot be defined precisely. Any one virus can produce a whole range of differing clinical manifestations and, conversely, any one clearly defined clinical syndrome may be initiated by a number of entirely different viruses. Laboratory tests offer some help in clarifying the present confused position and with their extensive use in the future a fuller understanding and control of respiratory diseases should become possible. THE COMMON COLD The main features of a cold are an intense nasal eatarrh in the absence of fever or any marked constitutional disturbance. There are many different types of colds. They arise from the ways in which the inflammatory oedema spreads to produce pharyngitis, laryngitis, bronchitis or sinusitis. Essentially a cold is an infection of the superficial mucous membranes. ‘After an incubation period of about 24 hours the familiar streaming of the nose begins and is followed on the next day with a muco-purulent discharge. The symptoms subside in a day or two and, provided there are no com- plications, disappear within three or four days Cold Viruses ‘The group of Rhinoviruses is the most important of all the agents that cause colds. There are about 50 serotypes that can be cultivated only in human embryonic cells and are designated as H strains. There have so far been described a further seven M strains which grow well in monkey kidney cells. Rhinoviruses are small in size, about 30 mp in diameter. They contain RNA and in many respects resemble enteroviruses with which they are classified as picornaviruses. Enteroviruses are also not infrequently associated with colds, and the Coxsackie A 21 strain (Coe) is constantly able to produce colds in volunteers. Coxsackie B viruses and some ECHO strains (¢.g., 11 and 22) also have this property. Myxoviruses, especially the para-influenza viruses I, 2 and 3 and res- piratory syncytial virus, often give rise to the symptoms of a cold, ‘There are many small microorganisms as well as the viruses which produce cold-like illnesses. Mild infections with Rickettsia burnetii (Q fever) and with the pleuropneumonia-like organism Mycoplasma pnewnoniae often present as colds. Tt must also be remembered that the symptoms of coryza may occur as prodromata of generalised viraemic illnesses, and that they may herald the appearance of such other effects as the rash in measles or chickenpox. 150 This depend discharges. Tha During the secretions and if After treatment embryo kidney Institute strains range 5-7 and a virus are inoct only a few foci d virus are used (Fig. 142), B The eytopal strain of humaate For the r inoculate prim: temperature is the respiratory identified by the their cytopathicCOMMON COLD LaBporaToRY DIAGNosis This depends mainly on the isolation of the infecting virus from the nasal discharges. The viruses are seldom present in faeces. During the first three days of the illness a swab is well soaked in nasal secretions and if possible sent immediately to the laboratory in the unfrozen state After treatment with antibiotics the material is inoculated into primary human embryo kidney cells or into human diploid fibroblast cells such as the Wistar Institute strains WI 26 and WI 38. The cultures should have a pH value in the range 5-7 and are incubated in a roller drum at 33°C. When small amounts of virus are inoculated the cytopathic effect may be minimal and ten days later only a few foci of altered cells can be found. When larger infective doses of the virus are used a marked cytopathic effect is sometimes seen within 48 hours Zz ES ¥ ‘A. Normal uninoculated human embryo lung eels. 1B! The eyigpathic effet produced by'a ehinovieus (FEB strain) three days after inoculation into & strain of human embryo Tung eels (Unstained) «80 For the recovery of viruses other than thinoviruses it is’ necessary to inoculate primary monkey kidney cells, HeLa and HEp2 cells. The incubation temperature is 34°C. Influenza and para-influenza viruses, adenoviruses, and the respiratory syncytial virus grow well under these conditions. They are identified by their haemagglutination and haemadsorption reactions and ‘by their cytopathic effects. 151CLINICAL VIROLOGY Serological tests for antibodies to Rhinoviruses are not a practical pro- position for diagnostic work because there are so many virus serotypes. They are, however, valuable in establishing the significance of a newly isolated virus. Complement-fixation and haemagglutination and haemadsorption inhibition tests are usefull when myxoviruses or adenoviruses are the infecting agents. ConrRoL There are innumerable popular measures recommended for the prevention and treatment of the common cold but there is no scientific evidence to suggest that any are of real value. A virus vaccine has been prepared using a rhinovirus (HGP strain). Its in- Jection was followed by an antibody response and when the recipient volunteers were challenged by the instillation of the homologous virus into the nose, they were found to be resistant to infection. (M.R.C. Report, 1965.) Much work remains to be done before it can be decided whether it may be possible to develop a vaccine capable of protecting the community against the prevailing wild rhinoviruses of the day, EPIDEMIC INFLUENZA The symptoms of an acute attack of influenza are usually quite different from those of a common cold. ‘The infecting myxovirus is inhaled and after an incubation period of 48 hours there is an abrupt onset of fever with the tempera- ture rising quickly to 102—104°F. A severe headache, suffusion of the con- junctivae, aching of the muscles of the back and limbs, and a sense of extreme fatigue oblige the victim to take to his bed. Coryzal symptoms are seldom prominent and the main complaint is of the prostrating fever itself with dryness of the throat and hoarseness of the voice. ‘The fever usually declines after three to four days and, provided that there are no complications, settles to normal within a week The influenza viruses exert a selective action on ciliated epithelium (Fig. 143), When they are instilled into the nasal passages of ferrets the respiratory epithelium is destroyed within 48 hours, leaving only the basement membrane (Fig.144). Regeneration and repair follow in the succeeding days and pass through the stages of transitional, stratified squamous and hyperplastic epithelium formation before normal ciliated cells are re-established, In man the infective process is limited to those areas of the bronchial tree that are covered by ciliated epithelium. It is for this reason that the larynx, trachea and the main bronchial tree are principally involved. The terminal respiratory bronchioles are lined by cuboidal, non-ciliated, non-mucus- secreting cells and therefore escape damage by the virus. Tn uncomplicated viral influenza there is no clinical or radiological evidence of involvement of the lungs, but when secondary bacterial invasion occurs the inflammatory reaction spreads more deeply and bronchiolitis, pneumonitis and bronchopneumonia follow. 152 Lefi section of the a erre 48 hours al enithliom ‘sts boomINFLUENZA, Fra. 143 A seetion of normal bronchial mucous membrane. The epitlial sxishave many tia prouding it the meno he bronchus ta (Haematim and cosh) Fig. 144 efi setion ofthe nas mucosa ofthe snout of normal feet. Right, a similar section taken from 48 hours after it had received an intra-nasal dose of influenza virus A. ‘The nasal respiratory plhoium has been complealy Gesteoyed and only the underlying baseneat membrane Yona Tete is extee congstion of esl (Herald eosin)CLINICAL VIROLOGY The outstanding feature of this type of influenza is that it gives rise, during the winter, to sudden outbreaks of infection, Some are limited to small foci but others are endowed with the ability to spread far and wide with astonishing rapidity. An epidemic soon becomes obvious from the great number of victims that it claims amongst the population; schools may have to close, public transport grinds to a halt, hospitals become flooded with emergency admissions and doctors in general practice are overpowered by much extra work, Two viruses—Myxoviruses influenzae A and B—are the principal agents at work but the very large epidemics are always caused by virus A or its variants, Influenza A ‘There is an uneven periodicity of the epidemics caused by Virus A. Once in about 40 years a great pandemic spreads rapidly to involve the whole world, The last time this happened was in 1957 when the Asian pandemic, originating in Southern China, spread East and West to encircle the world and engulf the populations of all the countries in influenzal infection (Fig. 145). The pandemic previous to this occurred in 1918 when it assumed such terrifying severity that about 20 million people died of the disease. There had been a pandemic before this in 1889-90 and looking back into the past it seems that there have been some 30 pandemics between 1510 and 1965, Between the great pandemics somewhat smaller epidemics (prevalences) occur at four to five year intervals. Since 1933, when the influenza virus A was first isolated, severe outbreaks have occurred in the winters of 1936-37, 1943-44, 1946-47, 1950-51 and 1957-58 (the pandemic year), Fi. 145 A diagram to indicate the spread of infection dking the 1957 pandemic of “Asian influenza, ‘The ‘oFigin of the epidemic in China s sen as a circle and dots in ved. 154 ‘The appearang of a new antigenic is exceedingly pl genically novel. ¥ the population do is freely transmiss from previous Thus the epidemic: from the original virus which was t Influenza B This virus outbreaks of infi during most of usually well cire as a boarding se especially capable not spare tena: is less liabie to B infections. Influenza C It is know distributed in that this virus & festations of infe infections of the The clinical virus is isolated The power of the) throughout the quickly (Fig. Influenza ¥ from the pati cultures. They by the inhibiti Influenza virus +hacmagglutinati findings become weeks if repeatINFLUENZA The appearance of an epidemic of influenza is associated with the emergence of a new antigenic conformation on the surface of the virus particle. Virus A is exceedingly plastic and readily gives rise to new mutants that are anti- genically novel. When such a mutation occurs the pre-existing immunity of the population does not protect it against the new influenza and if the virus is freely transmissible an epidemic follows. If the mutant diverges very far from previous antigenic types the epidemic may assume pandemic proportions. Thus the epidemic of 1946-47 was due to the Al virus which differed appreciably from the original A virus of 1933 and only barely resembled the A? Asian virus which was to follow in 1957 Influenza B This virus seldom, if ever, is responsible for explosive and extensive outbreaks of influenza. Endemic incidents and sporadic cases occur irregularly during most of the winter months. Epidemics due to influenza B virus are usually well circumscribed and involve perhaps some closed community such as a boarding school or occasionally a whole town or even a city. Virus B is especially capable of infecting young children of school age though it does not spare teenagers, It is more stable, antigenically, than virus A and thus is less liabie to variation. A longer interval occurs between epidemics of virus B infections. Influenza C It is known, from antibody surveys, that influenza virus C is widely distributed in the population of Britain, There is little evidence to suggest that this virus can cause epidemic influenza, ‘The symptoms and clinical mani festations of infections with virus C indicate that it produces only very mild infections of the upper respiratory tract ot colds. LaBorarory DiaGNosis The clinical diagnosis of influenza is confirmed when the infecting myxo- virus is isolated and a significant rise of antibody titre can be demonstrated The power of the influenza viruses to agglutinate red blood cells is made use of throughout the laboratory procedures and enables the viruses to be recognised quickly (Fig. 146) Influenza viruses are isolated either by inoculating oropharyngeal secretions from the patient into the amniotic cavity of chick embryos or into tissue cultures. They are identified by their haemagglutination patterns (p. 76) and by the inhibition of this property by highly specific standard antisera (p. 77). Influenza virus C will grow only in the amniotic cavity. It is unique in that its haemagglutination activity occurs only at low temperatures (4°C.). Laboratory findings become available after about five days but may require up to three weeks if repeated blind passage is required.CLINICAL VIROLOGY Fro, 146 An clectronmicrograph of thre ‘ghost’ fow erythrocytes whose surfaces are smothered with mytiads of adherent virus particles some of which fasion the red cells to eachother This the nomenon, of hemagglutination, The two isolation methods are of nearly equal sensitivity provided an incubation temperature of 33—35°C. is used. Primary monkey kidney cells probably offer the best system for influenza B viruses. In the authors’ experience chick embryos give a better isolation rate for influenza A viruses. Compiement-fixation tests (and haemagglutination-inhibition tests) on paired sera give retrospective information about the nature of the infection (pp. 87 and 88). INFECTIONS WITH PARA-INFLUENZA VIRUSES ‘These viruses affect children more than adults and produce @ mildly feverish illness with rhinitis, laryngitis, pharyngitis and bronchitis. The tem- perature is about 100°F. and in most instances the illness lasts for about two or three days. The para-influenza viruses, especially types 1 and 2, are associated closely with croup (spasmodic laryngo-tracheobronchitis). Clinically the child presents an alarming picture. The first attack often occurs on waking. There is an arrest of respiration with the child becoming very cyanosed as it struggles for 156 breath. After a! down into the accompanied Para-infl portion pro monolayer is haemadsorption only with dif diagnosis but are: inhibition tests antigens with logical tests arePARA-INFLUENZA breath. After a little the laryngeal spasm is suddenly released and air is drawn down into the lungs with a highly pitched crowing sound. The attack may be accompanied by convulsions or tetany. Para-influenzal infections are usually short lived and only a small pro- portion proceed to bronchiolitis or bronchopneumonia. Laporatory DiaGNosis Para-influenza viruses grow well in primary monkey kidney, primary human amnion, human embryonic kidney, HeLa and HEp2 cells. Usually they produce little or no cytopathic effect and their presence in the cells of the monolayer is detected by haemadsorption (Fig. 147). Specific antisera inhibit haemadsorption and thus enable the virus to be identified. These viruses grow only with difficulty in eggs Sw “ 4 Fa. 7 ‘A monolayer of monkey kidney ci hich ben nected 48 houry Dreviously with parasnfuenca IIT virus. A weak suspension of re fells was then flooded over the cell sheet and allowed to react before the surplus was removed. Novice the adsorption of guinea-pig ted ‘blood cells (arrows) tothe surface ofthe Infected cells, (Unstained) 100 Complement-fixation tests are used for serological confirmation of the nosis but are not yet fully reliable. Haemadsorption and haemagglutination inhibition tests are also of value. Because the para-influenza viruses share antigens with mumps virus and some other myxoviruses the results of sero- logical tests are often difficult to interpret. 157