COVID-19 and RSV: Coinfection Requiring Hospitalization

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Urgent message: Coinfection with COVID-19 and other respiratory pathogens can lead to a worsening clinical picture and requires careful assessment in the urgent care center.

Marcia Taylor, MD, MSCR, FAAFP

Citation: Taylor M. COVID-19 and RSV: coinfection requiring hospitalization. J Urgent Care Med. 2023;17(10):28-29.

Key words: COVID-19, SARS-CoV-2, RSV, coinfection, pandemic

ABSTRACT

Patients who present with symptoms suspicious for COVID-19 and other respiratory conditions, regardless of vaccination status, may require a higher acuity of medical care (although mortality may not be affected). This case report describes a case of COVID-19 and respiratory syncytial virus coinfection which necessitated hospital care despite the individual being vaccinated against COVID-19.

 INTRODUCTION

During the autumn of 2022, clinicians saw the rise of three different respiratory pathogens: COVID-19, respiratory syncytial virus (RSV), and influenza. This allowed for the possibility of coinfections among these three viruses. Although research is still evolving in this area, available studies have found that individuals coinfected with influenza required higher use of ICU and mechanical ventilation.^1-3 However, there was no increase in mortality.^1-3 Less research is available for coinfections with RSV as studies generally found lower numbers of this when compared to influenza. There appeared to be a similar trend of more medical treatment modalities needed, but no increase in mortality.^1,2 The following is a case presentation of a vaccinated individual with a coinfection requiring hospitalization.

PATIENT INFORMATION

A 69-year-old male presented with a 3-day history of sore throat, cough, nasal congestion, subjective fever, and minimal dyspnea. He had exposures to several family members who were diagnosed with pneumonia, but denied exposure to COVID-19. His past medical history was significant for hypertension and daily smoking. He did received the initial series of COVID-19 vaccine plus two boosters. His last booster was approximately 14 weeks prior to presentation.

CLINICAL FINDINGS

Vital signs were temperature 98.9°F, pulse 113, blood pressure 133/71, respirations 18, and room air oxygen saturation of 78%. He was in no acute distress and was able to give his history in complete sentences despite his hypoxia. Lungs were clear to auscultation bilaterally. Cardiovascular exam was significant for tachycardia, but revealed no murmur, rub, or gallop. Abdominal exam was soft and nontender with normal active bowel sounds. HEENT exam was significant for erythema of nose and oral pharynx with clear rhinorrhea.

Diagnostic Assessment

Given his level of hypoxia and that this was diagnosed in an ambulatory office setting with limited resources for continued care of severe hypoxia, a very brief and rapid assessment of patient’s symptoms were obtained. He was placed on 2L of oxygen via nasal canal and oxygen saturation improved to 98%. Due to his hypoxia and tachycardia, an ECG was obtained to evaluate for any arrhythmia or myocardial injury that may have been contributing to his symptoms. This ECG revealed normal sinus rhythm and no acute ischemic changes.

Differential diagnosis at this time included COVID-19, bacterial pneumonia, and pulmonary embolism. However, given that the patient had been vaccinated against COVID-19 it was unusual that he was presenting with such severe hypoxia.

PCR testing for SARS-CoV-2/RSV/influenza was obtained in office, but results were not available prior to the patient being transported to the hospital. Chest x-ray was not obtained due to the portable system not being available.

The patient was transferred to the emergency department via ambulance services. Chest x-ray obtained in the ED did not reveal any acute process. D-dimer obtained in the ED was negative. While in the ED, his PCR test returned positive for both COVID-19 and RSV. He was admitted to the COVID-19 unit of the hospital and treated with IV steroids and remdesivir. His clinical condition improved and he was discharged from the hospital 7 days later. At hospital follow-up 8 days later his symptoms were resolved; he denied any breathing difficulties and no longer required supplemental oxygen.

DISCUSSION

Two studies’ coinfection rates of influenza and RSV ranged from 8.3% to 22.3% and 16.7% to 22.3% ,respectively.^4,5 Researchers have theorized that coinfection may induce a more severe inflammatory response and thus a worse clinical picture. Studies have suggested that patients with coinfection were more likely to require hospitalization, longer ICU stays, and longer mechanical ventaliation.^1-3

Recent NIH guidelines state that coinfections have been reported and may complicate both the patient’s treatment and recovery.⁶ CDC guidelines state that a positive test for COVID-19 or influenza does not exclude that the other virus could be present.⁷ As the fall of 2022 saw a rise in both RSV and influenza compared with prior years, further research will be needed in this field to develop guidelines and treatment algorithm for patients with coinfection. As coinfections do have an increased risk in morbidity, but likely not mortality,^1-3 these patients need to be treated with available antiviral treatments for the offending virus.⁷ These patient may also necessitate closer follow-up (as telehealth or home pulse oximetry monitoring) given the higher need for hospital treatments.

INFORMED CONSENT

The patient consented to publication of this case report.

Manuscript submitted December 14, 2022; accepted March 27, 2023.

References

1. Cong B, Deng S, Wang X, Li Y. The role of respiratory co-infection with influenza or respiratory syncytial virus in the clinical severity of COVID-19 patients: a systemic review and meta-analysis. J Glob Health. 2022;12:05040.
2. Al Sulaiman K, Aljuhani O, Badreldin HA, et al. The clinical outcomes of COVID-19 critically ill patients co-infected with other respiratory viruses: a multicenter, cohort study. BMC Infect Dis. 2023;23(1):75.
3. Adams K, Tastad KJ, Huang S, et al. Prevalence of SAR-CoV-2 and influenza coinfection and clinical characteristics among children and adolescents aged <18 years who were hospitalized or died with influenza – United States, 2021-2022 influenza season. MMWR Morb Mortal Wkly Rep. 2022;71(50):1589-1596.
4. Hashemi SA, Safamanesh S, Ghasemzadeh-Moghaddam H, et al. High prevalence of SARS-CoV-2 and influenza A virus (H1N1) coinfection in dead patients in Northeastern Iran. J Med Virol. 2021;93(2):1008-1012.
5. Trifonova I, Christova I, Madzharova I, et al. Clinical significance and role of coinfections with respiratory pathogens among individuals with confirmed severe acute respiratory syndrome coronavirus-2 infection. Front Public Health. Epub ahead of print September 22, 2022. Available at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.959319/full. Accessed December 7, 2022.
6. National Institutes of Health. COVID-19 treatment guidelines. Available at: https://www.covid19treatmentguidelines.nih.gov/. Accessed March 30, 2023.
7. Centers for Disease Control and Prevention. Clinical Care Considerations. Clinical considerations for children and adults with confirmed COVID-19. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/clinical-considerations-index.html Accessed March 30, 2023

Author affiliations: Marcia Taylor, MD, MSCR, FAAFP, Lexington Medical Center, Batesburg–Leesville, SC. The author has no relevant financial relationships with any commercial interests.