Common Cold.

Sinusitis.

The paranasal sinuses are air-filled spaces in the skull located in the brow area over the eyes, inside each cheekbone, behind the bridge of the nose, and behind the eyes. Each sinus has an opening into the nose for the free exchange of air and is lined with a continuous mucous membrane. Healthy sinuses are sterile, but an infection or an allergic reaction can cause one or more of the sinuses to become inflamed or infected. Inflammation causes edema and the collection of mucus within the sinus cavity, creating a feeling of pressure, nasal congestion or rhinorrhea, and classic sinus headaches. The location of sinus pain depends on the sinus cavity involved but can be described as pain in the forehead (frontal sinuses), upper jaw and teeth discomfort (maxillary sinuses), pain between the eyes (ethmoid sinuses), and/or an earache and neck pain (sphenoid sinuses). The condition is treated with decongestants, antibiotics for bacterial infections, and analgesics. Sinusitis can be acute, lasting 2 to 8 weeks, or chronic, with symptoms lingering much longer.

Allergic Rhinitis (Hay Fever).

Although not caused by a pathogenic organism, allergic rhinitis frequently is confused with infectious disease. This disorder affects millions of people every year. It is caused by a reaction of the nasal mucosa to an environmental allergen. The most common allergen is plant pollen; this is where the term “hay fever” originated. Signs and symptoms include sneezing, nasal congestion, nasal itching, and rhinorrhea. Symptoms can be controlled either with OTC treatments, such as Sudafed, Zyrtec, and fexofenadine hydrochloride (Allegra), or with prescription antihistamines, such as montelukast (Singulair), and fluticasone (Flonase) and cromolyn sodium (Nasalcrom) nasal sprays. The list of possible allergens is extensive. When this condition is seen in the respiratory practice, the patient usually is referred to an allergist for testing and possible immunotherapy.

Patients may have difficulty determining whether symptoms are caused by a cold or an allergy. The condition usually is an allergy if the eyes, ears, nose, throat, and roof of the mouth (palate) are itchy; the eyes are red and watery; a clear, thin nasal discharge is present; symptoms are seasonal and last for weeks or months; and the individual does not have a fever.

Pneumonia.

Pneumonia can occur in any age group but most often affects preschoolers and the elderly (over age 65). It can range from a mild complication to a life-threatening illness. Risk factors include smoking, alcoholism, and immunosuppression caused by diseases or treatment. The patient usually comes to the office with symptoms of high fever, chills, and general malaise. Signs of the illness include dyspnea, tachypnea, chest pain during inspiration, and a relentless cough with possible hemoptysis. Auscultation of the chest reveals rales, rhonchi, and other signs of pulmonary consolidation. The infection may spread into the pleural cavity, causing empyema and pleurisy.

The diagnosis is confirmed with a chest x-ray evaluation; sputum culture and sensitivity testing to identify the invading organism and determine the appropriate antibiotic therapy; and a white blood cell (WBC) count, including a differential count to determine whether the pneumonia is viral or bacterial. If the pneumonia is viral, the number of WBCs does not increase; if it is bacterial, the greater the invasion, the higher the WBC count. With bacterial pneumonias, the differential count shows elevated neutrophil and monocyte levels. If the invading organism is bacterial, the treatment of choice is antibiotics and lung function therapy until the patient has recovered. If the organism is viral, the patient is given supportive care, such as antipyretics, fluids, and oxygen, until the immune system can control the spread of the virus.

Tuberculosis.

According to the Centers for Disease Control and Prevention (CDC), approximately one third of the world’s population is infected with tuberculosis (TB). TB causes more deaths than any other infectious agent in the world. For more than 50 years, the incidence of TB in the United States steadily declined; however, from the late 1980s through the 1990s, a resurgence in reported cases occurred. This increase was believed to be the result of increased travel and immigration; the number of individuals with AIDS, who have little resistance to disease; an increase in the number of homeless and malnourished people; and the overwhelming proliferation of drug-resistant TB bacilli. An international TB vaccine, bacille Calmette-Guérin (BCG), is available, but it is rarely used in the United States. The vaccine does not always provide protection from the disease and those who are vaccinated may have a positive Mantoux test result.

TB is caused by the bacterium Mycobacterium tuberculosis. This organism is covered with a waxy substance that enables it to survive outside a living host for a long time. It is transmitted by droplets of sputum expectorated into the environment by an infected host that are inhaled by another person. In the warm, moist respiratory tract, these organisms again can become active if the individual is susceptible to the disease. TB also can be spread when an infected person coughs or sneezes, releasing airborne infected droplets, which are inhaled and cause an infection if the person is susceptible.

TB develops in two stages. The primary infection occurs when the person is first infected with the bacteria and the lungs become inflamed. Cell-mediated immunity ensues, isolating the bacteria and forming a tubercle. At this point a healthy individual can stop the spread of infection, causing the TB bacillus in the tubercle to become inactive. In this case, the person was exposed to the pathogen but never developed active disease and so is said to have a latent TB infection. Individuals with latent TB are asymptomatic and are not infectious. However, because an exposed person develops antibodies to the disease, he or she consistently tests positive on TB skin screening tests. Therefore, rather than the purified protein derivative (PPD), or Mantoux test, these patients should have chest x-ray studies to diagnose active TB.

TB is diagnosed most frequently in people living in crowded conditions with poor hygiene, those who are malnourished, and those who have other chronic conditions. It spreads most rapidly in large cities, in the elderly, alcoholics, and the homeless. Symptoms of an active infection include an intermittent fever that peaks in the afternoon, night sweats, weight loss, and general malaise. As the infection becomes virulent in the host, a productive cough develops, and thick, dark, frequently blood-tinged mucus is expectorated.

The primary diagnosis of TB is established through the patient’s signs and symptoms. The infection is suspected with a positive chest x-ray film but is confirmed with a sputum culture. Traditional culture methods originally took 4 to 6 weeks, and this extended period allowed a potentially infectious individual to continue to spread the disease. New culture techniques identify the bacterium in as little as 36 to 48 hours. The physician also may order a blood test, the QuantiFERON-TB Gold test (QFT), to diagnose TB infection. The QFT measures the response to TB proteins when they are mixed with a small amount of blood. A two-step Mantoux test is recommended for individuals who are over age 45 and have never had a Mantoux test; those who have been vaccinated with BCG; and employees of hospitals and long-term care facilities. For this test, the initial intradermal skin test is administered and read in 48 to 72 hours. If the result is negative, a second Mantoux is performed on the opposite arm 1 to 3 weeks after the first test and again read in 48 to 72 hours.

Once a diagnosis of TB has been confirmed, the patient is prescribed long-term treatment with a combination of drugs to eradicate the bacilli. If the patient has tested positive for TB but does not have an active infection, the physician prescribes isoniazid (INH) and rifampin (RIF) for 6 months to treat any possible tubercle formations. If the patient has active pulmonary TB, the CDC recommends a four-drug regimen—INH, RIF, pyrazinamide, and ethambutol—daily for 2 months; this is then reduced to two drugs for an additional 4 to 7 months, depending on sputum culture outcomes. It is crucial that patients being treated with TB medications strictly comply with medication orders to prevent the creation of multidrug-resistant TB (MDR-TB). Resistant strains of TB develop because of skipped doses or failure to take the medication as long as prescribed. MDR-TB requires at least 2 years of drug therapy with medications that can cause serious side effects, especially liver damage. All tuberculin-negative healthcare workers should have a PPD annually; workers who show a positive reaction but are not actively infected with TB should have an annual chest x-ray evaluation to screen for the disease.