Overview of the Different Types of Respiratory Infections


Experts provide an overview of the clinical presentations of respiratory infections such as COVID-19, influenza, and respiratory syncytial virus.

Tina Tan, MD: Now that we’re talking about these diseases, Kevin, can you provide a brief overview of the clinical presentations of the different types of respiratory infections? Can you comment on the early onset of the respiratory viral season, especially flu and RSV [respiratory syncytial virus] that has occurred this year?

Kevin Michael Reiter, MD, PA: Yes, absolutely. The presentations, as we all know, have a lot of overlap, which makes it a little challenging, and I think that’s where testing comes into play. But a lot of times, dependent on the vaccine status of the individual for flu or COVID-19, we may see fever, body aches, fever up to 103, 104 °F, fatigue, headaches, sore throat, cough, and nasal congestion. In the past when somebody walked in with that, we had a saying in our urgent care, if it walked like a duck and talked like a duck, it was probably a duck in the peak of flu season. Now, unfortunately, that’s not true anymore because COVID-19 came to town, and with the varying strains of COVID-19 that we’ve seen over the years, the presentations are so different. I’m seeing a lot of flu-like symptoms now where I’m looking at somebody, I’m saying, “You have the flu,” and then I’m handed the positive COVID-19 test result, and I’m like, “Oh, I guess it’s COVID-19.” That’s where the testing strategy really comes into play.

I think we’re seeing an earlier season because for the last 2 years we saw a lot of masking, a lot of distancing, a lot of folks weren’t getting that normal low-level exposure and building up some degree of immunity. So I think now we’re seeing it hitting everybody all at once. It’s similar to the early days of COVID-19 is what I think of. In someone who’s naive to the virus in those first weeks to months of the infection, before there were antiviral medications, and before we knew a whole lot about it, it was this immune response, this over activity of immunity and the immune system, which I think is responsible for a lot of what we’re seeing now in folks who have been naive to RSV, adenoviruses, enteroviruses, rhinoviruses, influenza, and of course the varying strains of COVID-19.

Tina Tan, MD: Priya, do you have something to add?

Priya Nori, MD: Certainly. I would emphatically agree with everything that’s been said. What comes to mind for me is the fact that we have such good home diagnostics now for COVID-19. What I tell patients these days is, let’s say that you test positive for COVID-19 at home, but not you’re not improving in the way that you thought, or you received treatment and you’re not improving in the way that you thought. Well, go and get yourself tested for these other viruses like RSV and flu because it may be that you’re coinfected. Or that you had COVID-19 before and you have some residual virus, but truly what’s causing you to be symptomatic is one of these other viruses. Personally, I would love to see in the next, let’s say 18 months or so, that there is an approved or at least authorized home test that can pick up all of these 3 viruses. I think that would be a game changer in terms of access, speediness of treatment, and off-loading the health care system. We need to be moving toward that.

Tina Tan, MD: Wendy, do you have something to add?

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I’m a huge diagnostician, and we all have learned, this is the presentation for this and that. I’ll tell you, all bets are off at this point. I’d like to tell you that if they lose their smell and their taste, it’s definitely COVID-19, but with the Omicron strain, we’re not seeing that as much. I had someone today who has a low-grade fever and diarrhea, and she’s positive for COVID-19. I think there was a study that came out, Tina, that said over 60 symptoms have been reported with COVID-19.

Tina Tan, MD: Correct.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: We’re seeing this trifecta, and I think we have a lot of work to do as educators and clinicians because people aren’t thinking about RSV in adults.

Tina Tan, MD: I know, and that’s unfortunate.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: That’s a challenge, right?

Tina Tan, MD: That is unfortunate.

Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Because those tests are not being run. Now granted, we’re going to treat them probably similarly whether we know or don’t know with RSV, particularly in our adults. But this early testing is crucial, and we began to see RSV in July and August, totally outside the RSV season. We have point-of-care testing for all of this, so we’re able to identify it. But we began to see flu type B. Historically, I don’t see flu B until March. I don’t know what the rest of you see, but we’re seeing flu B, we’re seeing flu A, and I had someone yesterday who had influenza and COVID-19. So, all bets are off, and I think it’s already a tough system. It’s a tough system when you know that in December the urgent care centers are saying, “We can’t see you for 2 days.” It’s really frightening out there because people can’t get early intervention, they can’t get tested early, and some of these folks are waiting in EDs [emergency departments] for hours and days for evaluation. It’s definitely a tough season right now.

Tina Tan, MD: JAM, do you have something to add?

Jacinda Abdul-Mutakabbir, PharmD: I will say that I completely and wholeheartedly agree with every single thing everyone said. I don’t know that I have anything of much value to add. One thing I will say is that my mother recently had COVID-19. While we don’t know what strain it was, she complained that she did not lose her appetite because she said she wanted to slim down for the holidays. Thankfully she was fine, but I think that what Wendy highlighted, it’s so important for us moving forward with how we manage these different diseases if they don’t look the way they did previously. They’re ever-evolving, and we have to be prepared for that, which is why testing is so important.

Tina Tan, MD: I agree. I think it’s even more important in the pediatric population because the way that children present with these different diseases is not the same as an adult. For example, with influenza, many of the younger children may only present with GI [gastrointestinal] symptoms. They may have a fever, and they may have nausea, vomiting, diarrhea, and not very much else until later. So the sudden onset of fever, chills, cough, sore throat, etc, does not always happen in very young children. Similarly with RSV, in very young babies, all you may see is a child who’s having increased work of breathing and then apnea, and that may be the presentation of RSV for these young babies. Which is not what you typically see in some of the older children, so definitely there is a bit of a difference with regard to the way some of these viral infections can present. But there’s a lot of overlap.

Transcript edited for clarity

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