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Uvulitis caused by parainfluenza virus
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  1. Ryunosuke Nomura and
  2. Katsuhiko Kitazawa
  1. Department of Pediatrics, Asahi General Hospital, Asahi, Chiba, Japan
  1. Correspondence to Dr Ryunosuke Nomura; ryunomu.0606{at}gmail.com

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Description

Infective uvulitis is a rare condition characterised by inflammation and oedema of the uvula. The major causes of uvulitis in children were Haemophilus influenzae type b (Hib) and group A streptococcus (GAS), prior to the introduction of the Hib vaccine. Especially in Hib uvulitis, the bacteraemia was an occasional complication.1 Widespread vaccination efforts have significantly reduced the incidence of invasive Hib infections. In countries where infants are fully immunised against Hib, the main cause of infective uvulitis has become GAS.2 Candida albicans has been reported as another cause of uvulitis.3 However, the recent reports are limited, and there is a lack of updated information regarding the epidemiology and antimicrobial treatment of uvulitis.2 To our knowledge, there have been no previous reports on viral uvulitis. In this report, we describe the first case of uvulitis induced by the parainfluenza virus and discuss the necessity of antibiotics for uvulitis.

A 1-year-old boy presented with dysphagia and fever for 2 days. In line with the Japanese immunisation schedule, he was completely vaccinated against Hib. On admission, he had a temperature of 39.1°C, heart rate of 174 beats per minute, respiratory rate of 32 breaths per minute and oxygen saturation of 96% on room air. Intermittent drooling was observed. On physical examination, he had pharyngeal erythema and a 10 mm significantly swollen spherical uvula (figure 1). Blood testing revealed a white cell count of 11.3×109/L, C reactive protein of 0.18 mg/L and procalcitonin of 0.05 ng/mL. The rapid diagnostic antigen test using a throat swab sample yielded a negative result for GAS. Considering his vaccination history and laboratory findings, his disease was less likely caused by a GAS or invasive Hib infection. However, he was treated with cefotaxime in case of bacterial infection, while awaiting microbiology results. On the following day, he exhibited minimal clinical improvement. Stridor was also noted during episodes of crying. As epiglottitis and abscess formation in the posterior pharynx were ruled out via laryngeal fiberoptic and contrast-enhanced CT, it was considered a croup symptom associated with airway inflammation. On the third hospitalisation day, his stridor and drooling resolved, but the temperature remained high at 38.0°C. Culture of blood and uvula were negative for GAS, Hib and C. albicans. Treatment with cefotaxime was terminated. After discontinuation of the antibiotic, his symptoms, including swelling of the uvula, gradually resolved. He was discharged on the fifth hospitalisation day. A month later, parainfluenza virus type 3 was isolated from a uvula swab, obtained during the initial examination.

Figure 1

Swollen and erythematous uvula.

The patient in the present case exhibited minimal clinical improvement after receiving antibiotic therapy, and his symptoms gradually improved after the discontinuation of his antibiotics. This clinical course was consistent with the natural history of a viral infection. The parainfluenza virus preferentially infects ciliated epithelial cells in the upper and lower airways.4 Based on this, uvulitis secondary to a parainfluenza virus infection was strongly suspected. Furthermore, the parainfluenza virus is the leading cause of croup in children.4 The simultaneous resolution of the croup and swelling of the uvula also suggested a viral uvulitis caused by the parainfluenza virus. If a rapid test such as a film array had been conducted instead of a viral identification test, it would have played a part in the clinical decision to stop the antibiotic. Since Hib infections have been nearly eradicated due to vaccination efforts, it is reasonable to assume that viral infections are a primary consideration among children who are completely vaccinated against Hib presenting with uvulitis and a negative antigen test for GAS. Nowadays, broad-spectrum antibiotics may not be necessary.

Patient’s perspective

The following statement is the view of the patient’s mother.

The Author translated what she wrote into English.

My son had a high fever and difficulty in swallowing. I assumed that he had a cold. He was prescribed medication, but wheezing and drooling started at midnight, and he could no longer take in fluids, therefore we visited the pediatrician the following morning. On examination, his uvula was significantly swollen and the pediatrician informed me that he also might have epiglottitis. I first learned that epiglottitis is an emergency disease that worsens respiratory conditions, therefore I would rush to see a doctor if he had similar symptoms in the future. He was hospitalized and treated with antimicrobials. Because I had heard that there was a possibility of epiglottitis, I agreed to see an otolaryngologist to assess the risk of airway obstruction. At the time, I was extremely anxious.

Learning points

  • Parainfluenza virus type 3 can cause uvulitis.

  • Viral uvulitis may potentially be identified if investigations are performed.

  • Since Haemophilus influenzae type b infections have nearly been eradicated due to vaccination efforts, antibiotic therapy may no longer be necessary for children with a complete vaccination history and unremarkable laboratory findings.

Ethics statements

Patient consent for publication

Acknowledgments

We would like to thank Editage (www.editage.jp) for English language editing services.

References

Footnotes

  • Contributors RN managed the patient, drafted the initial manuscript and approved the final manuscript prior to submission. KK critically reviewed and revised the manuscript, and approved the final manuscript prior to submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.