Infections

All patients with asthma may experience a worsening of their symptoms concurrent with upper respiratory tract infections, bronchitis, or influenza-type illnesses. Moreover, children may experience their initial asthma as a consequence of viral bronchiolitis, which commonly develops into chronic asthma. Finally, some patients have no clinical asthma except during concurrent respiratory infections. Some adult asthmatics trace their chronic asthma to a viral respiratory infection that led directly to chronic and often severe, nonallergic asthma.

Bronchiolitis is an acute viral infection of the bronchioles, generally seen only in children less than 2 yr old. It is usually accompanied by upper respiratory tract symptoms, which may precede the lower respiratory tract involvement by 2-3 d. Patients experience cough (sometimes croup), dyspnea, rapid respirations, fever, and sometimes prostration. Physical examination reveals retractions, rapid respiration, occasional rales, and wheezing. Respiratory syncytial virus (RSV) is the most frequent etiological agent, but adenoviruses, rhinovirus, parainfluenza virus, and others may also cause the disease.

RSV-related bronchiolitis has a mortality risk of 1%. Several studies suggest that atopic children develop IgE antibodies directed at the RSV, which converts the infection into an allergic reaction. About 50% of children with bronchiolitis in whom a family history of either allergies or asthma exists develop recurring wheezing. In most instances, postbronchiolitis asthma is mild in nature and largely under control or in remission by the age of 8 yr. Current studies suggest that some patients with asthma may have an underlying bronchitis caused by Mycoplasma or Chlamydia infection. Such patients generally have adult-onset disease, associated with an initial infection and some persistent cough and mucus production. In such patients, a 1- to 2-mo trial of appropriate antibiotics (such as Clarithromycin, 500 mg bid) might be helpful. Information of the possible relationship between a low-grade infection and asthma is suggested by increased antibody titers against Mycoplasma and/or Chlamydia or the presence of bacterial RNA in lung biopsy.

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