Human Meta Pneumo Virus (HMPV) Management of severe pneumonia, with respiratory failure

A. Nagarajan

Senior Consultant – Pulmonologist, Kauvery Hospital, Cantonment, Trichy

Case presentation

A middle-aged woman had a 10-day history of fever, cough and cold, 3 days of breathing difficulty and one episode of blood-stained sputum, with no comorbidities.

Initially managed at a local hospital with antibiotics and supportive medications. Referred with severe dyspnea and respiratory failure.

On Examination

Dyspneic and tachypnic

  • HR – 124/min
  • RR – 52/min
  • SpO2 – 64% on room air
  • On NIV
  • RR – 48–50
  • Spo2 – 100, with FiO2 40%

Investigations

CT- Chest

Diagnostic Test

  • Nasal swab
  • Multiplex -PCR

HMPV – Detected

Treatment

  1. Supportive care
  2. Antibiotics
  3. Antiviral
  4. Corticosteroids

On day 5

CT-Chest Comparison

Discharged on day 5

Discussion

Human metapneumovirus (hMPV) is a common cause of acute respiratory tract infections (ARIs). It commonly infects-

  • Children
  • Adults
  • Elderly
  • Immunocompromised patients

Paediatric group

  • Acute respiratory tract infection (ARI) is a leading cause 20% of total deaths in children less than 5 years of age. Common in children less than 2 years of age.
  • < 6 months of age, with HMPV infection, three times  more likely to be hospitalized.

 

  • Common symptoms of URTI- Cough, rhinorrhea, congestion, and sore throat or croup.
  • LRTI-Bronchiolitis, Bronchitis and Pneumonia, exacerbation of asthma. Similar presentation to hRSV, difficult to differentiate.

The commonly associated infections

  • ENT- Acute Otitis
  • GI – Nausea, vomiting , diarrhoea
  • CNS-Febrile seizures, Encephalitis

Average duration of fever in hMPV-positive is 10 days.

Adult

Clinical manifestations

  • Fever, cough
  • Upper respiratory tract infection
  • Lower respiratory tract infection
  • Dyspnea , wheezing
  • Acute exacerbation of asthma, COPD
  • Bronchitis/Bronchiolitis
  • Severe pneumonia

Risk Factors for severe infection

  • Premature birth
  • Younger age
  • Asthma, COPD
  • Chronic heart/Kidney/Neuro disease
  • Liver/Renal/BM transplant

Human Metapneumovirus (HMPV)

HMPV was first discovered in Netherlands on 2001.

Characteristics of HMPV

  1. Lipid-enveloped
  2. Single-stranded
  3. Negative-sense
  4. Non-segmented RNA virus Pneumoviridae family
  5. Metapneumovirus genus

HMPV-Co-Infection

  1. RSV
  2. Bocavirus
  3. Rhinovirus or enterovirus
  4. Parainfluenza virus
  5. Coronavirus
  6. Influenza A
  7. Influenza B
  8. Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae.

Mode of infections

  1. Respiratory droplets
  2. Incubation period 3-5 days
  3. High levels of hMPV viral shedding lasted from 1 to 2 weeks after acute illness
  4. Re-infection may occur due to different viral genotypes or insufficient immunity.

Pathogenesis

  1. Chemokines
  2. Cytokines
  3. Peribronchiolar, Perivascular infiltration and inflammation
  4. Intra-alveolar foamy Haemosiderin-laden Macrophage Smudge cells
  5. Alveolar damage,
  6. Hyaline membrane disease

Other Diagnostic Tests

  1. Immunofluorescence assays
  2. Direct fluorescent antibody

X ray Chest

  1. Non Specific
  2. Bronchitis
  3. Pneumonia
  4. Peribronchial/Parahilar opacities (87%)
  5. Atelectasis (40%)
  6. Consolidation (18%)
  7. Hyperinflation

Fig: Peribronchial/Parahilar opacities

Fig: Bilateral Peribronchial Ground glass opacities and Centrilobular nodules

Fig: Lobar Consolidation

Management Plans

  • Primarily supportive care
  • Oral/ IV hydration
  • Supplemental oxygen
  • NIV
  • Invasive ventilation

Medical Management

  • Ribavirin – oral/ IV/aerosol
  • Polyclonal intravenous immunoglobulin
  • Fusion inhibitors
  • RNA interference
  • Live Attenuated vaccine on research.

Preventive Measures

Droplet precaution

Proper hand washing.

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