Ho, HK

New England Journal of Medicine

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Title Human metapneumovirus and lower respiratory tract disease inchildrenAuthor(s) Ho, HKCitation New England Journal of Medicine, 2004, v. 350 n. 17, p. 1788-1790Issued Date 2004URL http://hdl.handle.net/10722/145841Rights New England Journal of Medicine. Copyright © MassachusettsMedical Society. The  new england journal  of  medicine n engl j med  350;17 www.nejm.org april  22, 2004 1788 correspondence Human Metapneumovirus and Lower Respiratory Tract Disease in Children to the editor:  The case definition of croup givenby Williams et al. in their study of metapneumovi-rus (Jan. 29 issue) 1  seems misleading. The authorsstate that croup is an “acute lower respiratory tractinfection characterized by hoarseness, cough, andstridor.” On the contrary, croup is classified as anacute upper-airway disease in several textbooks ofpediatrics. 2-4  Recognizing croup as an importantcause of acute upper-airway obstruction and itspertinent features, as distinct from life-threateningbacterial epiglottitis, is the classic point made inmedical teaching worldwide. Hok-Kung Ho, M.B., B.S. University of Hong KongHong Kong, Chinaa8914760@graduate.hku.hk 1. Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumo-virus and lower respiratory tract disease in otherwise healthy infantsand children. N Engl J Med 2004;350:443-50. 2. Orenstein DM. Acute inflammatory upper airway obstruction.In: Behrman RE, Kliegman RM, Arvin AM, eds. Nelson textbook ofpediatrics. 15th ed. Philadelphia: W.B. Saunders, 1996:1201-5. 3. Healy G, Avery ME. Upper airway disorders. In: Avery ME, FirstLR, eds. Pediatric medicine. 2nd ed. Baltimore: Williams & Wilkins,1994:1347-56. 4. McKenzie S, Silverman M. Respiratory disorders. In: CampbellAGM, McIntosh N, eds. Forfar & Arneil’s textbook of pediatrics. 5thed. New York: Churchill Livingstone, 1998:489-583. to the editor:  Williams et al. show that “humanmetapneumovirus infection is a leading cause ofrespiratory tract infection in the first years of life,with a spectrum of disease similar to that of respi-ratory syncytial virus.” In a surveillance study per-formed from November 1, 2002, to March 31, 2003,among 1331 healthy children younger than 15years of age who were seen for acute respiratory in-fection in an emergency department in Milan, Italy,we found evidence of human metapneumovirus in41 children (3.1 percent), of respiratory syncytialvirus in 117 (8.8 percent, P<0.001 for the compari-son with human metapneumovirus), and of influ-enzavirus in 209 (15.7 percent; P<0.001 for thecomparison with human metapneumovirus) (Ta-ble 1). Although the overall prevalence of humanmetapneumovirus in our study population ap-peared to be lower than the prevalence of respirato-ry syncytial virus and that of influenzavirus, weshowed that this pathogen has multiple effects. Weconfirmed that infection with human metapneu-movirus has clinical characteristics similar to thoseof infection with respiratory syncytial virus, 1,2  butits socioeconomic effect appeared to be greaterthan that of respiratory syncytial virus infectionand similar to that of influenzavirus infection. 3,4 We would like to know whether the authors ob-served the same socioeconomic burden on chil-dren and their families in association with humanmetapneumovirus infection. Nicola Principi, M.D.Susanna Esposito, M.D.Samantha Bosis, M.D. Institute of Pediatrics20122 Milan, Italynicola.principi@unimi.it THIS   WEEK ’ S   LETTERS 1788 Human Metapneumovirus and Lower Respiratory Tract Disease in Children 1790 Monkeypox in the Western Hemisphere 1791 Off-Pump versus On-Pump Coronary Bypass Surgery 1794 Interferon Gamma-1b for Pulmonary Fibrosis 1797 The Severe Acute Respiratory Syndrome 1798 Medical Malpractice 1798 Treatment of Refractory Neurosarcoidosiswith CladribineThe New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF HONG KONG LIBRARIES on March 26, 2012. For personal use only. No other uses without permission.  Copyright © 2004 Massachusetts Medical Society. All rights reserved.  n engl j med  350;17 www.nejm.org april  22, 2004 correspondence 1789 1. Mejías A, Chávez-Bueno S, Ramilo O. Human metapneumovi-rus: a not so new virus. Pediatr Infect Dis J 2004;23:1-10. 2. Esper F, Boucher D, Weibel C, Martinello RA, Kahn JS. Humanmetapneumovirus infection in the United States: clinical manifesta-tions associated with a newly emerging respiratory infection in chil-dren. Pediatrics 2003;111:1407-10. 3. Principi N, Esposito S. Are we ready for universal influenza vac-cination in paediatrics? Lancet Infect Dis 2004;4:75-83. 4. Principi N, Esposito S, Marchisio P, Gasparini R, Crovari P. So-cioeconomic impact of influenza on healthy children and their fam-ilies. Pediatr Infect Dis J 2003;22:Suppl:S207-S210. the authors reply:  In response to Dr. Ho: we agreethat the croup is usually poorly defined, partly be-cause of differences between anatomical and physi-ological descriptions of this illness. Two standardtextbooks of pediatrics define croup, or laryngotra-cheobronchitis, as both a cause of “upper airway ob-struction” and “lower respiratory tract” infection. 1,2 The classic pathophysiology involves subglottic tra-cheal edema (the “steeple sign” seen on radiographsof the airway). The World Health Organization de-fines lower respiratory tract infection as the pres-ence of tachypnea, retractions, stridor, wheezing, orapnea. 3  We think that recognition of croup as a dis-tinct clinical syndrome is more valuable than a def-inition based on anatomical terms and define it assuch in our article. There are an estimated 65,000annual hospitalizations for croup in children lessthan five years old in the United States, thus war-ranting such a distinction and underscoring theimportance of croup as a clinical entity. 4 In response to the interesting data presented byDr. Principi and colleagues: information about theage distribution of the patients they describe wouldhelp in the interpretation of the data. As we state inour article, all the children we studied were lessthan five years old and thus not in school. We didnot collect data on parents’ time off from work orother socioeconomic costs associated with illness-es due to human metapneumovirus infection. How-ever, since the mean duration of symptoms beforemedical attention was sought was 4.4 days, and 37percent of the children had concomitant acute oti-tis media, it is likely that there is a significant socio-economic burden associated with disease causedby human metapneumovirus, as has been describedfor other respiratory viruses. 4 Finally, we would like to clarify the financialsupport of our research. The work was supportedby grants (T-32 AI07474 and R03 AI054790 [bothto Dr. Williams] and R00095 [to the General Clini- * RSV denotes respiratory syncytial virus, and hMPV human metapneumovirus.† P<0.001 for the comparison with influenzavirus-positive children. ‡ P<0.05 for the comparison with RSV-positive children. Table 1. Clinical Characteristics and Outcomes among Children Seen in the Emergency Department for Acute Respiratory Infection and Effects among Their Household Contacts, According to Viral RNA Detection.*CharacteristichMPV-Positive (N=41)RSV-Positive (N=117)Influenzavirus-Positive(N=209) Clinical presentation — no. (%)Common coldPharyngitisAcute otitis mediaCroupAcute bronchitisWheezingPneumonia3 (7.3)11 (26.8)5 (12.2)3 (7.3)4 (9.8)10 (24.4)†5 (12.2)20 (17.1)20 (17.1)10 (8.5)4 (3.4)15 (12.8)30 (25.6)†18 (15.4)43 (20.6)73 (34.9)34 (16.3)7 (3.3)20 (9.6)14 (6.7)18 (8.6)Clinical outcomeHospitalization — no. (%)Lost school days — no.MedianRange2 (4.9)103–1516 (13.7)103–1211 (5.3)125–15Effects among household contactsSimilar disease — no./total no. (%)Lost work days — no.MedianRangeLost school days — no.MedianRange18/149 (12.1)‡42–10‡43–15‡20/420 (4.8)2.52–722–474/767 (9.6)‡41–10‡51–15‡The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF HONG KONG LIBRARIES on March 26, 2012. For personal use only. No other uses without permission.  Copyright © 2004 Massachusetts Medical Society. All rights reserved.  The  new england journal  of  medicine 1790 n engl j med  350;17 www.nejm.org april  22, 2004 cal Research Center]) from the National Institutesof Health and by a Vanderbilt University Discoverygrant (to Dr. Crowe). John V. Williams, M.D.James E. Crowe, Jr., M.D. Vanderbilt UniversityNashville, TN 37232james.crowe@vanderbilt.edu 1. Behrman RE, Kliegman RM, Arvin AM, eds. Nelson textbook ofpediatrics. 15th ed. Philadelphia: W.B. Saunders, 1996.  2. Rudolph AM, ed. Rudolph’s pediatrics. 20th ed. Stamford,Conn.: Appleton & Lange, 1996. 3. Emerging and communicable diseases: surveillance and con-trol. Geneva: World Health Organization, 1997. 4. Henrickson KJ, Hoover S, Kehl KS, Hua W. National diseaseburden of respiratory viruses detected in children by polymerasechain reaction. Pediatr Infect Dis J 2004;23:Suppl:S11-S18. Monkeypox in the Western Hemisphere to the editor:  Infection control was a major issuefor investigators attempting to minimize the emer-gence of monkeypox in the United States, as report-ed by Reed et al. (Jan. 22 issue). 1  On June 7, 2003,three Illinois residents with a febrile rash syndromepresented to a community hospital. Hospital staffreported the cases that evening to the Illinois De-partment of Public Health, which recommendeddiagnostic testing, collection of contact informa-tion, and admission under contact and airborneprecautions.Infection control was efficiently implemented,despite the absence of preexisting policies specificto this pathogen and uncertainty regarding bestpractices for the prevention of person-to-persontransmission. 2  The hospital’s participation in theTop Officials 2 (TOPOFF 2) bioterrorism exercisein May 2003, 3  smallpox training activities, and pastmanagement of an imported case of Lassa fever 4  en-hanced the execution of infection-control protocols.This outbreak tested a hospital’s preparednessto respond to an unusual communicable agent.Had the outbreak been larger, the hospital’s isola-tion facilities would have been insufficient. Hospi-tals should critically evaluate their capacity to imple-ment rapid syndrome-based isolation precautionsfor emerging disease outbreaks. 5 Gregory D. Huhn, M.D., M.P.H.T.M. Centers for Disease Control and PreventionChicago, IL 60601ghuhn@idph.state.il.us Robert A. Chase, M.D. Central DuPage HospitalWinfield, IL 60190 Mark S. Dworkin, M.D., M.P.H.T.M. Illinois Department of Public HealthChicago, IL 60601 1. Reed KD, Melski JW, Graham MB, et al. The detection of mon-keypox in humans in the Western hemisphere. N Engl J Med 2004;350:342-50. 2. Jezek Z, Grab B, Dixon H. Stochastic model for interhumanspread of monkeypox. Am J Epidemiol 1987;126:1082-92. 3. Top Officials (TOPOFF) exercise series: TOPOFF 2: after actionsummary report for public release. Washington, D.C.: Department ofHomeland Security, December 19, 2003. (Accessed April 1, 2004,at http://www.dhs.gov/interweb/assetlibrary/T2_Report_Final_Public.doc.) 4. Holmes GP, McCormick JB, Trock SC, et al. Lassa fever in theUnited States: investigation of a case and new guidelines for man-agement. N Engl J Med 1990;323:1120-3. 5. Bioterrorism readiness plan: a template for healthcare facilities.Washington, D.C.: Association for Professionals in Infection Con-trol and Epidemiology, Centers for Disease Control and Prevention,April 13, 1999. (Accessed April 1, 2004, at http://www.apic.org/educ/readinow.cfm.) to the editor:  In their report on the U.S. monkey-pox outbreak (72 cases), Reed et al. cite Africanoutbreaks of 23 and 88 cases. By doing so, the au-thors risk minimizing the magnitude of the prob-lem in Africa, where the disease has been endemicsince the 1970s, with multiple outbreaks, includ-ing one outbreak of 419 cases in 1996–1997. 1  Thelarge size of this African outbreak may have resultedfrom increased contact with animals in a popula-tion of persons displaced by civil war. 2  High ratesof human exposure to monkeypox may occur inother scenarios, such as the infection of wild ro-dents in U.S. cities.The animal reservoir for human monkeypox re-mains unknown. 3  Although prairie dogs are theprobable source of transmission in most U.S. cases,there has been human transmission from other spe-cies. A rabbit (Leporidae family) that was exposedto a diseased prairie dog was implicated as thesource of human infection in at least one U.S. case. 4 Daniel B. DiGiulio, M.D.Paul B. Eckburg, M.D. Stanford University School of MedicineStanford, CA 94305digiulio@stanford.edu 1. Human monkeypox — Kasai Oriental, Democratic Republic ofCongo, February 1996–October 1997. MMWR Morb Mortal WklyRep 1997;46:1168-71.The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF HONG KONG LIBRARIES on March 26, 2012. For personal use only. No other uses without permission.  Copyright © 2004 Massachusetts Medical Society. All rights reserved. 

Human metapneumovirus and lower respiratory tract disease in children

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Human metapneumovirus and lower respiratory tract disease in children

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