Case Presentation: An 81-year old male with a significant medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease, was admitted to the hospital complaining productive cough, shortness of breath and pleuritic chest pain from one week. Chest X-ray revealed left lower lobe consolidation with left parapneumonic effusion. The nasopharyngeal swab was positive for Rhinovirus by PCR. The pleural fluid was highly inflammatory (Lactate dehydrogenase greater than 1000) but had no bacterial or fungal growth. Contrast chest CT scan was done on day 2 of admission due to worsening dyspnea revealing left pleural based lung mass and adjacent abscess. Biopsy of lung mass was consistent with organizing pneumonia with few focal cocci in the abscess area on gram stains. Bronchoscopy showed thick mucus secretions in the left main stem bronchus and no intraluminal defect. Gram-positive antimicrobial agents were empirically administered, but additional antiviral therapy was not started. The patient subsequently underwent video-assisted thoracoscopy, left pleural decortication and chest tube placement with symptom relief in 3 days.
Discussion: Human rhinoviruses (HRVs) were once considered to cause relatively benign upper respiratory tract illness, however now they are linked to severe lower respiratory tract diseases including complicated pneumonia in elderly. HRVs are transmitted via contact or aerosol and capable of causing both interstitial and alveolar inflammatory processes primarily based on T-cell activation, resulting in increased expression of Interleukin-6 (IL-6), IL-8 an IL-16. Moreover, HRV can stimulate the synthesis of vascular endothelial growth factor, transforming growth factor and fibroblast growth factor. Meanwhile, organizing pneumonia is a nonspecific inflammatory process resulting from numerous causes. The histopathology of organizing pneumonia is based on lung fibroinflammatory process starting from alveolar injury leading to colonization of fibroblast and associated fibrin deposition. The alveolar architecture is preserved. Mechanism of HRV-induced organizing pneumonia and direct role of the virus itself and host immune response is still under debate. Factors associated with poor outcomes include the interstitial pattern on imaging, secondary bacterial infection, associated pulmonary disorders and histological findings of scarring and remodeling of lung parenchyma. The video-assisted thoracoscopic lung biopsy is preferred diagnostic tool. Corticosteroids are the current standard treatment and spontaneous resolution is occasional.
Conclusions: 1. Physicians should be aware of severe rhinovirus infection leading to rare complications like secondary organizing pneumonia.
2. Elderly patients are susceptible to severe illness from Rhinovirus requiring aggressive diagnostic workup and treatment.